Prirztrd in Dminrrrk
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011 rrghrs reserved
Acta Obstetricia et
Gynecologica Scandinavica
ISSN 0001-6349
ORIGINAL ARTICLE
~~
Posttraumatic stress reactions after emergency
cesarean section
ELSALENARYDING',
BARBRO WIJMA' AND
KLAASwIJMA2
From the Departments of Obstetrics and Gynaecology, 'Central Hospital, Helsingborg and *University Hospital, Linkoping,
Sweden
Acto Obstet Gjwecol Sctmd 1997; 76: 856-861. 0 Acta Obstet Gynecol Scand 1997
Back~roiml.The study aimed at answering the following questions: Do women experience
emergency cesarean section as traumatic?
Do women experience any posttraumatic stress reactions or even posttraumatic stress disorder
(PTSD) one to two months after emergency cesarean section?
method.^. Twenty-five consecutive women were interviewed a few days and one to two months
after emergency cesarean section.
Results. Nineteen (76%) of the 25 women had experienced their delivery by emergency cesarean section as a traumatic event. One to two months postpartum none of these women met
all the diagnostic criteria of PTSD. However, 13 women had various forms of posttraumatic
stress reactions and in eight cases (33%) symptoms of serious posttraumatic intrusive stress
reactions.
Conclusions. The emergency cesarean section was in the majority of the cases experienced as
a mental trauma. Although none of the women suffered from PTSD one to two months
postpartum, one third had serious posttraumatic intrusive stress reactions. The concept of
traumatic stress thus seems to be relevant for investigations of psychological aspects of emergency cesarean section.
Key u.ords: emergency cesarean section; psychology; PTSD; trauma
Suhmiticd 2.7 Scptc~mbcr.,1996
Ar.r,c!ptd23 Dwember., 1996
In Sweden the frequency of cesarean section has
increased during the last 20 years and at present
represents about 11% of all deliveries. About 60%
of these operations are emergency cesarean sections (I). The obstetrical complications of emergency cesarean section are well studied, while prospective research concerning the psychological
consequences for the women is scant.
In clinical reports, women have expressed their
experiences of emergency cesarean section as a
mental trauma, comparable to a sudden accident
(2, 3, 4, 5 , 6). The unanticipated cesarean section
has been emphasized as a potential risk factor for
Ahhwvintion:
PTSD: posttraumatic sti-css disorder.
0 Actcr Obstet Gynecol Scund 76 (1997)
mental problems postpartum (7). When compared
with women having spontaneous vaginal or forceps delivery, women having emergency cesarean
section had a six times higher risk of developing
postpartum depression (8).
A retrospective study of records of 34 consecutive multiparous women, who had their latesl delivery by means of elective cesarean section due to
psychosocial indications (i.e. for private reasons
without any obstetric indications) at Helsingborg
Hospital 1983-87, showed that half of the patients
had previously experienced a traumatic delivery by
means of an emergency cesarean section. In a prospective interview study (1988-90) of 28 parous
pregnant women who demanded a cesarean section
for personal reasons and without any obstetric in-
dications, all had very bad memories of their previous deliveries (1 1 cases ending in an emergency
cesarean) which was the basis of their demand
(10).
Thus, women after emergency cesarean section
seem to be an important group to investigate, in
order to expand knowledge about the mental condition and needs of mothers after a potentially distressing delivery, with the aim of developing routines for clinical care for this group.
The concept of posttraumatic stress reactions
according to DSM 111-R (1 1) seems to offer an
appropriate diagnostic model for studying the
psychological reactions in women who have gone
through emergency cesarean section. A person
who has experienced an event ‘outside the range
of usual human experience which would be markedly distressing to almost anyone’ (criterion A)
may afterwards more or less demonstrate a specific set of mental symptoms. The person may reexperience the traumatic event in a distressing
way during nightmares, flashbacks and intrusive
recollections of the event (criterion B). The person is unable to choose whether she or he wishes
to think about the trauma or not. Avoidance of
stimuli and feelings associated with the trauma
leads to avoidance of situations that bear similarities to the trauma and to a numbing of general
affective responsiveness (criterion C). Persistent
symptoms of increased arousal, such as sleep disturbance, irritability and difficulties to concentrate are also part of the posttraumatic stress reactions (criterion D). If the symptoms persist for
a month or more (criterion E), the diagnostic criteria of posttraumatic stress disorder (PTSD), according to DSM 111-R, are fulfilled. Any other
demonstrable stress response syndrome which fulfils some of the criteria mentioned above, is, in
this study, categorized as a ‘posttraumatic stress
reaction’.
Conflicting evidence has been presented concerning whether a premorbid personality of a potential victim may increase the risk of developing
posttraumatic stress reactions (1 2). PTSD research
has generally confirmed the ‘common sense’ idea
that the more serious the trauma is, the more serious the posttraumatic reactions will be. The vulnerability of the individual also plays a part, as
some individuals do and others do not develop
PTSD after the same situation.
The aim of the present study was to answer the
following questions:
Do women experience an emergency cesarean
section as a traumatic event?
Do women have PTSD or any posttraumatic
stress reactions after an emergency cesarean section which was experienced as a traumatic event?
-
a trauma
857
Material and methods
Helsingborg Central Hospital is the only hospital
in a town of about 100 000 inhabitants. The Department of Obstetrics and Gynecology has about
2300 deliveriedyear from a catchment area of
38 000 female inhabitants aged 1 5 4 4 years. During the study period the cesarean section rate was
about 9%, 60% of which were emergency cesarean
sections.
Twenty-six
consecutive
Swedish-speaking
women, who underwent an emergency cesarean
section, were asked to participate in the study,
which entailed being interviewed twice. Only
mothers of living children were invited. One of
these women had twins. One woman could not
participate because she was transferred with her
critically ill child to another hospital for special
treatment. None of the patients declined to be
interviewed in the maternity ward, but one did not
return to participate in a second interview, one to
two months after delivery. Twenty-three of the operations were unanticipated; two had been planned
for a few days later, but had to be performed
earlier, in an emergency situation, because of onset
of labor.
With one exception (see above) each participant
was interviewed twice (interviewer E L R). In connection with an explorative interview about the
women’s experiences of childbirth by emergency
cesarean section a thorough investigation was
made of the existence of the various diagnostic criteria of posttraumatic stress reactions and of
PTSD according to DSM 111-R (10). The experience of the cesarean section was categorized as
traumatic (criterion A) if the woman reported one
or more of the following: She had been very frightened she would die or be hurt or she had been very
frightened to lose the baby or to deliver a seriously
ill or handicapped child, or she had lost contact
with reality in a very frightening manner. The detailed DSM 111-R criteria B-D of PTSD were followed strictly.
The first interview took place in the maternity
ward, a few days (mean 4 days, range 1-9 days)
after childbirth. (Three of the interviews had to be
postponed until day 7-9 because the women received intensive care and could not be disturbed.)
The second interview was performed one to two
months (average 40 days, range 29-69 days) after
delivery. The second interview took place at least
one month postpartum according to the DSM criterion E.
The following biographic and obstetric variables
were collected from the hospital records: age and
parity of the women; full gestational weeks at the
time of delivery; indications for cesarean section;
0 Acta Obsfet Gynerol Scand 76 (1997)
16000412, 1997, 9, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.3109/00016349709024365, Wiley Online Library on [08/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Emergency cesarean section
Age
32
26
31
35
23
32
42
28
26
25
31
36
27
26
28
31
32
35
25
36
35
28
35
25
26
Participant
number
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
1
2
0
0
1
1
0
0
0
0
0
0
1
0
1
0
2
1
0
2
1
3
0
1
1
31
36
42
41
35
41
37
38
41
31
41
31
37
40
40
34
41
40
41
37
40
38
39
38
43
preterrn breech twins
dis-proportion
susp fetal asphyxia
protracted delivery
placenta previa
susp fetal asphyxia
susp fetal asphyxia
protracted delivery
susp fetal asphyxia
pre-eclampsia
protracted delivery
transverse presentation
breech disproportion
genital herpes
protracted delivery
pre-eclampsia
breech disproportion
protracted delivery
protracted delivery
protracted delivery
placental ablation
susp fetal asphyxia
protracted delivery
susp fetal asphyxia
susp fetal asphyxia
Complete
gestational Indication for
Parity
weeks
cesarean section
60 min
100 min
24 min
40 rnin
30 rnin
86 min
60 min
60 min
60 min
60 min
10 min
15 min
60 min
10 min
45 rnin
7
38 mtn
10 min
17 min
39 min
30 rnin
34 min
140 min
42 min
180 min
Time from
decision to
beginning of
operation
9-1 0
4-8
1-3
9-1 0
66
8-1 0
9-10
8-1 0
9-1 0
8-1 0
9-9
7-8
%9
4 4
7-9
9-1 0
9-1 0
7-9
9-1 0
9-1 0
8-1 o
8-1 o
2 4
9-1 0
9-10
8-8
Apgar
score
1-5 min
Baby to
pediatric
unit
Partner present
at hospital (H),
operation (0)
generaI
general
general
general
general
general
general
general
general
general
general
general
general
general
general
general
general
general
general
general
spinal
general
general
epidural
+general
general
Anesthesia
A
AB
ABC
-
AB
BD
ABC
AD
AC
AB
AB
-
ABD
-
A
A
A
B
ABD
ABD
-
AD
A
AB
A
a few days
postpartum
5
A0
31
30
30
7
2
-
36
36
30
69
43
35
31
31
35
32
35
32
AB
AB
6
5
2
2
1
6
29
34
-
9
3
4
1
2
4
1
2
6
4
AD
D
AB
A
A
missing
A
-
ABD
-
A
AB
AB
-
a
AD
AD
-
66
61
53
52
53
34
31
first second
1
5
2
3
3
Posttraumatic
intrusion (AB)
1-2 months
postpartum
AB
A
ABD
AD
1-2 months
postpartum
PTSD criteria
Days
postpartum for
interview
-
-
+
-
-
-
-
-
-
-
-
-
-
+
-
-
-
-
-
Planned
cesarean
section at later
date
Table I. Biographic data, obstetric data and prevalence of various posttraumatic stress reactions according to the specific criteria of the PTSD diagnosis in DSM Ill-R of 25 women submitted to emergency cesarean section.
Those six women who were clinically distressed and in need of additional help are marked by *
&
is
@
&
%
t”
h
16000412, 1997, 9, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.3109/00016349709024365, Wiley Online Library on [08/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
time from the decision of a cesarean section to the
beginning of the operation; Apgar score at one
and five minutes; transfer of the new-born child to
the pediatric unit; presence of the woman’s partner
at the hospital and at the operating-theater during
the cesarean section; mode of anesthesia.
The frequency of the various PTSD criteria in
relation to day postpartum of the first interview
was tested by Fisher’s exact test.
Results
Biographic and obstetric data and posttraumatic
stress reactions of the 25 women are displayed in
Table I.
Nineteen of the women participating in the
study had experienced their delivery by emergency
cesarean section as a traumatic event, as recorded
both a few days and (with one exception) one to
two months postpartum.
Thirteen of the 25 women had posttraumatic
stress reactions one to two months postpartum but
none of them completely met the diagnostic criteria of PTSD in terms of DSM 111-R. Table I1
displays the proportion of the women who fulfilled
the various criteria of posttraumatic stress reactions and of PTSD at the two interviews. There
was no demonstrable difference in the frequency of
the PTSD criteria between the women interviewed
one to four days after delivery (n=16) and the
women interviewed five to nine days postpartum
(n=9). Eight women fulfilled the PTSD-criteria A
and B about one to two months postpartum, i.e.
they had experienced their cesarean section delivery as traumatic (A), and had symptoms of intrusion (B). This combination seemed to be of clinical relevance as intrusive thoughts should normally have disappeared by this time. The average
day of interview was 43 in the group of eight
women with posttraumatic intrusive stress reactions and 38 in the group of 16 women without
Table II. The prevalence of posttraumatic stress reactions according to the
specific criteria of the PTSD diagnosis in DSM Ill-R at a few days (range 19 days) postpartum and at one to two months (range 29-69 days) postpartum
in a group of women submitted to emergency cesarean section
Specific criteria* of PTSD
Trauma (A)
Intrusion (B)
Avoidanceinumbing (C)
Persistent arousal (D)
B, C, and D persistent at least one
month (E)
A few days
postpartum
(n=25)
One-two months
postpartum
(n=24)
19 (76%)
12 (48%)
3 (12%)
6 (24%)
18 (75%)
8 (33%)
0
8 (33%)
* a woman may fulfil more than one criterion
0
-
a trauma
859
such reactions. During the second interview, six of
the eight women were considered to be clinically
distressed and in need of psychological treatment
(Table I). Four of these six were primiparous and
declared that they never wanted to go through a
trial of labor again due to their experiences, even
though at that point in time there were no obstetrical indications that they could not deliver vaginally
in the future. These four women said that they
wanted another child but only if they could be
guaranteed a delivery by means of an elective cesarean section. A fifth woman said that she would
avoid another pregnancy since nobody could
guarantee her that it would not be a cesarean section, whether elective or emergency. A sixth woman was consciously struggling very hard to hold
back very intrusive memories regarding her seriously complicated cesarean section. She had been
advised by her obstetrician never to have any more
children because of extensive abdominal scarring
and her refusal to accept a blood transfusion. This
woman was happy to apply for sterilization.
Discussion
Posttraumatic stress disorder (PTSD) is a widely
used concept in contemporary psychiatric research
(13). The PTSD model may be applicable to obstetrics since PTSD has been diagnosed after childbirth, according to recent reports (14, 15). None
of the women in the present study actually had
PTSD one to two months after an emergency cesarean section, but a traumatic delivery experience
was common, as were various posttraumatic stress
reactions. According to DSM-IV (16), which was
published after the present study had been completed, a stress-response syndrome which does not
meet all the criteria for PTSD is diagnosed as an
‘adjustment disorder’. For the purpose of this
study the term ‘posttraumatic stress reactions’ is
used to indicate those same reactions. The term
‘posttraumatic intrusive stress reactions’ specifically describes those reactions where the PTSD criteria A+B are fulfilled one to two months postpartum. Another new DSM IV diagnosis, ‘acute stress
disorder’, applies to a stress-response syndrome
with specified symptomatology occurring within
one month after the trauma and lasting for a minimum of two days and a maximum of four weeks
after the traumatic event. The diagnosis of an
acute stress disorder might be applicable to women
with posttraumatic stress reactions shortly after an
emergency cesarean section, but could not be used
in this study, since the presence and duration of
certain specified symptoms of mental dissociation
had not been assessed.
The majority of the women in this study des0 Actu Ohstet Gynecol Srurid 76 (1997)
16000412, 1997, 9, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.3109/00016349709024365, Wiley Online Library on [08/11/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Emergency cesarean section
E. L. Ryding et nl.
cribed their experience of delivery by emergency
cesarean section as mentally traumatic both a few
days and one to two months postpartum. The significance of these findings is uncertain. Comparison is needed with women who went through an
elective cesarean section or an uncomplicated or
instrumental vaginal delivery.
Why did none of the women, who reported a
traumatic delivery experience, develop PTSD?
Since emergency cesarean section is not very uncommon, one could argue whether the possible
mental trauma suffered is really ‘outside the range
of normal human experience’ (PTSD criterion A).
There is considerable difference between the experience of a major catastrophe, such as one resulting in loss of life, and the experience of an unanticipated cesarean section, resulting in a physically
healthy mother and child. Therefore, it is not surprising that the mothers in this study did not develop PTSD. It is likely that the trauma was not
serious enough. Equally, the criteria of the PTSD
diagnosis according to DSM 111-R may not be
suitable for the purpose of an investigation in the
postpartum period.
Intrusive thoughts, pictures and memories (criterion B of the PTSD diagnosis) were most easily
demonstrated and were common both a few days
and one to two months postpartum. According to
clinical experience, intrusive thoughts and memories are frequent among women a few days after
childbirth (1 7), but should have disappeared by
one to two months after birth.
Cognitive avoidance of the stimuli and feelings
associated with the trauma (part of criterion C)
was not frequently reported. However, five out 24
women stated that they would avoid any risk of
a future emergency cesarean section by avoiding
another pregnancy or by avoiding trial of vaginal
delivery. These reactions may be seen as a phobic
avoidance of the traumatic situation, fulfilling part
of criterion C. In Sweden repeat elective cesarean
sections are not routinely performed but only
when supported by additive obstetric indications.
The phobic avoidance by the woman may therefore
sometimes constitute great problems for the Swedish obstetrician. The pregnant woman may demand an elective cesarean section in opposition to
her obstetrician, who may insist that she should
have a vaginal delivery, as there is a lack of obstetric indication for an elective cesarean section.
Emotional numbing (part of criterion C) was
not demonstrated. There may be several reasons
for this. Firstly, the women perhaps felt it inappropriate to express a lack of maternal feelings in the
interview one to two months after delivery even if
they had such feelings. Secondly, an important
part of established treatment of PTSD is exposure
0 ALiu O h t e t Gynecol Scnnd 76 (1997)
to stimuli (thoughts, things, situations, behaviors
that remind the patient of the trauma). Thus, exposure to the new-born child might have been a
natural kind of treatment of posttraumatic stress
reactions after childbirth for some women, who
thereby have overcome a possibly existing numbing
feeling.
Persistent symptoms of increased arousal (criterion D) were demonstrated in six women a few
days postpartum and in eight women one to two
months postpartum. However, some of the symptoms listed in DSM TIT-R, such as sleep disturbance and difficulties of concentration, are common
among new mothers. Thus, the PTSD criterion D
was considered not suitable for these women during the postpartum period. The value of criterion
D has been questioned also regarding other groups
of patients with possible posttraumatic stress reactions (1 8).
Another possible reason for the absence of complete PTSD in this material is that the explorative
interview carried out a few days postpartum might
have functioned as some kind of a crisis intervention. Imaginal exposure, in which the contextual and emotional experiences of the trauma are
handled, has been used for decades with trauma
victims in order to prevent and treat mental symptoms (19).
The interviews were for practical reasons not
performed at the same day postpartum, which may
have influenced the results of the first interview.
According to Harding (20) the so-called postpartum blues or maternity blues starts between two
and four days after delivery, never lasting longer
than two weeks. The frequency of the various criteria of PTSD of the women could not be related
to day postpartum at the first interview. However,
the results of the second interview may be more
reliable.
The results of the present study need to be
strengthened in a larger sample of women subjected to emergency cesarean section. Comparison
has to be made with reactions of women experiencing other types of delivery. The diagnosis of relevant posttraumatic stress reactions may have to be
modified with respect to the characteristics of a
postpartum group of women.
One third of the women in the present study did
suffer from serious posttraumatic intrusive stress
reactions one to two months after the emergency
cesarean section. The condition, if not diagnosed
and treated, may lead to problems during the first
important months of the woman’s relationship
with her baby. We do not know the impact of such
posttraumatic intrusive reactions on either the
women’s or the children’s future mental health, nor
on the outcome of future pregnancies. According
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860
to clinical experience, however, women who exaggerate the dangers of the delivery and underestimate their own capability to cope with it, anticipate a future pregnancy as a threat and are at risk
of experiencing a difficult and stressful delivery.
Untreated posttraumatic intrusive stress reactions
after emergency cesarean section may leave the woman with a negative mental picture of a potentially
dangerous delivery with which she was not able to
cope.
Acknowledgments
This study has been supported by research grants,from the Stig
and Ragna Gorthon’s Foundation and from Ostergotland’s
County Council.
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r
-
Address for correspondence:
Elsa Lena Ryding, M.D.
Department of Obstetrics and Gynaecology
Central Hospital
S 251 87 Helsingborg
Sweden
~
0 Acta Obstet Gynecol Scand 76 (1997)
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Emergency cesarean section