The psychological impact of childbirth: Unscheduled cesarean delivery associates with increased risk for acute stress response

Abstract

Introduction

Cesarean delivery is one of the most common surgical procedures in the United States. Despite their frequency and medical necessity, the acute psychological response associated with unscheduled cesarean delivery is unknown. This study aimed to assess the rates and nature of peritraumatic stress reactions during and shortly after unscheduled cesarean delivery, and whether acute stress predicts later mental health symptoms.

Methods

A total of 1146 patients receiving routine perinatal care at a single tertiary, urban hospital were assessed for peritraumatic stress reactions during the delivery hospitalization, on average 31 hours postpartum using the patient self‐report Peritraumatic Distress Inventory (PDI). 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.

Results

A total of 10.4% of participants met criteria for clinical acute stress (PDI ≥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 (ρ = 0.20, p = 0.005). Compared with vaginal delivery, unscheduled cesarean delivery was associated with a fourfold increased risk of acute stress (26.6% vs. 6.3%; relative risk = 4.20; 95% confidence interval [CI], 2.92–6.05). Adjusting for the interval between delivery and PDI completion (hours), 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 were 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 responses strongly predicted subsequent posttraumatic stress disorder (β = 0.48, p < 0.001) and depressive (β = 0.30, p < 0.001) symptoms and maternal–infant bonding (β = 0.32, p < 0.001) difficulties.

Conclusions

A 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.

1. INTRODUCTION

Childbirth represents one of the most physiologically intense experiences in human life, involving a coordinated surge in neuroendocrine, autonomic, immune, and pain‐regulatory activity to facilitate labor and delivery and maternal adaptation [1, 2, 3, 4, 5, 6]. Specifically, there are drastic changes in hypothalamic–pituitary–adrenal axis (HPA) regulation with heightened sympathetic activity and rapid parasympathetic restoration in the immediate postpartum [6, 7, 8].

A substantial percentage of births (∼32%) in the United States are by cesarean delivery (CD) [9], a major surgical procedure [10, 11] that in many cases is unscheduled or emergent [12]. An estimated one in five women in the first delivery undergo an unscheduled CD [13, 14] that is typically performed during active labor due to failure to progress or non‐reassuring fetal assessment [13, 14, 15] and intended to reduce maternal and neonatal morbidity and mortality [16]. Existing data show that unscheduled CD and/or the underlying indications for the procedure can be associated with short‐ and long‐term medical implications for maternal (e.g., increased risk of repeat cesarean and abnormal placentation in subsequent pregnancies) and infant health (e.g., increased risk of respiratory distress and altered gut microbiota) [17, 18, 19, 20, 21, 22]. However, far less is known about the psychological consequences of unscheduled CD, particularly its acute emotional impact and its enduring impact.

Unscheduled CD and the circumstances surrounding it may fulfill diagnostic and statistical manual of mental disorders (DSM‐5) Criterion A for exposure to a traumatic event, involving real or perceived threats to life or serious injury, either to the self or to others [23]. The unanticipated need for major surgery, especially in the context of prior physiological and emotional strain during active labor, may provoke intense emotional responses and perceived traumatization [24]. A large body of research has documented peritraumatic stress reactions that occur during or immediately after a traumatic event across various trauma‐exposed samples [25, 26, 27, 28, 29, 30, 31, 32, 33]. These responses are shown to be strong predictors of subsequent posttraumatic stress disorder (PTSD) [24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34], even more so than pre‐trauma vulnerability factors [32, 35]. Understanding the magnitude of peritraumatic stress associated with unscheduled CD, during an important time for the formation of maternal–infant bonding, may have implications for targeted screening and implementations of clinical approaches in labor and delivery and postpartum units to enhance postoperative recovery.

We hypothesized that given the potential traumatic experience of unscheduled CD and its acuity, compared to other delivery modes, it would be associated with more clinically significant acute stress responses during childbirth, accounting for prepartum and peripartum factors, which would remain enduring in the early postpartum period; and that acute stress predicts subsequent mental health symptoms and bonding problems.

2. MATERIALS AND METHODS

2.1. Study population

A total of 1146 women who recently gave birth and received routine perinatal care at a single tertiary, urban hospital, and completed an immediate postpartum assessment for acute stress were included in this study. Of these women, 340 (29.7%) underwent CD and 806 (70.3%) delivered vaginally. All participants were assessed during the third trimester for mental health and prior trauma (Time point 0), then on average 31 hours postdelivery (range = 0.4–120 hours) (Time point 1), primarily through in‐person evaluations conducted during their maternity hospitalization. A subgroup (n = 795, 69.4%) completed a second postpartum assessment approximately at 1.92 months post delivery (range = 0.6–2.67) (Time point 2). Completers were different on demographic background (i.e., maternal age, education, income, marital status, race and ethnicity), antepartum PTSD symptoms, and use of epidural. The sample is derived from two prospective, longitudinal cohorts of studies on the mental health sequelae and childbirth experiences. The cohorts targeted the similar population: third‐trimester patients who planned to deliver at the study hospital with recruitment occurring at different time periods: Cohort 1 between October 2016 and October 2022, excluding participants who gave birth during the COVID pandemic, with enrollment during routine perinatal visits and Cohort 2 from March 2023 with data available through January 2025 with recruitment via hospital's Patient Gateway portal. While the cohorts were largely the same on background factors, cohort 2 entailed more underrepresented minorities (Black and Hispanic), participants with higher income, and more antenatal depression and trauma history. Participants provided implied consent by completing the study questionnaires via Redcap after receiving detailed information about study procedures. The studies were approved by the hospital's Human Research Committee.

3. MEASURES

3.1. Mental health

Acute stress reactions to childbirth were assessed using the Peritraumatic Distress Inventory (PDI) [31]. This is a 13‐item questionnaire that measures emotional and physiological responses experienced during and shortly after a traumatic event [31]. Responses are rated on a 0 (Not at all) to 4 (Extremely true) scale with higher total scores indicating greater distress. The PDI demonstrates strong reliability and validity across trauma‐exposed populations and postpartum samples [25, 26, 27, 28, 29, 30, 31, 32, 34, 36, 37, 38, 39]; and clinical cutoff scores inform PTSD risk [27, 29, 30, 31, 40]. A cutoff score of 15 (excluding item 4) has been suggested to identify individuals at risk for childbirth‐related PTSD [41] and was used in the present study. Reliability of the PDI was high (α = 0.83).

Depression symptoms were assessed using the Edinburgh Postnatal Depression Scale (EPDS), the recommended screening tool for peripartum depression in clinical settings [42, 43]. EPDS scores were primarily obtained from participants’ medical records. A score of 13 or higher was used as the clinical cutoff indicating probable depression [42, 43, 44, 45].

PTSD symptoms were measured with the well‐validated PTSD Checklist for DSM‐5 (PCL‐5), a 20‐item self‐report questionnaire that assesses DSM‐5 PTSD symptoms [46, 47]. Items are rated on a scale from 0 (Not at all) to 4 (Extremely); higher total scores reflect greater symptom severity. The PCL‐5 demonstrates strong validity [47, 48], including in perinatal populations [49, 50]. A cutoff of 32 is used for a provisional PTSD diagnosis [47, 49, 51]. Reliability was high (for pregnancy, α = 0.93; for postpartum assessment specified to recent childbirth, α = 0.91).

Maternal–infant bonding problems were measured with the Maternal Attachment Inventory (MAI) [52]. This is a 26‐item self‐report questionnaire designed to assess mother's emotions and perceptions towards the infant and aligns with observational assessments. Items are rated on a 4‐point scale, with higher scores indicating stronger perceived bonding impairment (α = 0.92).

Trauma history was assessed using the Life Events Checklist for DSM‐5 (LEC‐5) [53], which captures exposure to various traumatic events (e.g., natural disasters, physical or sexual assault, sudden accidental death). The total number of events endorsed as “happened to me” was summed to generate a total trauma exposure score.

3.2. Obstetric information

Delivery mode based on electronic medical record data was categorized as vaginal, assisted vaginal (i.e., vacuum/forceps extraction), scheduled CD (including elective and/or clinically indicated), and unscheduled CD (including emergent cases based on the physician's indication). The latter group was categorized into non‐laboring (i.e., before the initiation of contractions, e.g., premature rupture of membranes (PROM) non‐vertex/non‐trail of labor after cesarean (TOLAC) candidate, newly diagnosed macrosomia, etc.) and laboring specified as; first or second stage of labor. Severity of obstetric complications was classified as: severe, life‐threatening conditions per the American College of Obstetrics and Gynecology (ACOG) [54] (e.g., uterine rupture, eclampsia and unplanned hysterectomy); moderate, significant morbidity or long‐term risk (e.g., fetal labor intolerance, hemorrhage ≥1500 cc, blood transfusion, third/fourth‐degree lacerations, and infant health complications); mild, short‐term complications (e.g., manual placenta removal without hemorrhage and failure to progress); or none. Additional medical record data included gestational age at delivery, primiparity, labor induction, and epidural administration.

3.3. Analysis

Missing data for single items for mental health measures (i.e., PDI, PCL‐5, EPDS, MAI for 3.04% of the mental health data) and other factors (i.e., demographics, trauma history, and obstetrical data for 3.85% of these data) (3.15% of the total data) were determined to be missing completely at random (MCAR) (Little's MCAR Test, χ²(10,901) = 4548.0, p = 1). Relevant missing information was handled with multiple imputation using the “mice” package in R [55]. Descriptive statistics were computed using proportions for categorical variables and means with standard deviations for continuous variables. Differences in rates of significant acute stress (PDI ≥15) and background, obstetrics, and mental health data were evaluated across delivery modes using chi‐square tests of independence (or Fisher's exact test) and analysis of variance performed for continuous variables. Comparisons for acute stress (primary outcome) by delivery mode included adjusted relative risks (aRRs) and were computed using log‐binomial regression, controlling for the interval between delivery and PDI completion (hours), demographics, mental health, and obstetric factors, if associated with PDI score (p ≤ 0.10). A repeated measures linear mixed model with Kenward–Roger adjustment was used to assess stability of stress levels between time points and across delivery modes, adjusting for identified contributors with planned post hoc analyses using estimated marginal means (EMMs) and Sidak adjustment to identify between‐ and within‐group changes. Stress rates were stratified by severity of obstetric complications (and labor stage for unscheduled CD). We further examined childbirth‐related PTSD, postpartum depression and maternal–infant bonding as secondary outcomes, using a regression analysis for the prediction of these outcomes by acute stress, controlling for obstetric factors. Statistical analyses were conducted in R (version 4.3.0) [56].

4. RESULTS

The mean maternal age was 33.7 (SD = 4.07) years; 38.4% of participants were primiparous. Most women (95%) delivered at full‐term and 70.3% had vaginal delivery, while 29.7% underwent CD. Obstetric complications were identified in 36.9% of cases with 0.2% life‐threatening complications. Table 1 presents sample demographics, prepartum mental health status, and obstetric information, all stratified by delivery mode.

TABLE 1.

Demographics, mental health, and obstetric factors by mode of delivery.

	Mode of delivery
	Unscheduled cesarean (n = 192)	Scheduled cesarean (n = 148)	Vaginal (n = 744)	Assisted vaginal (n = 62)
Characteristics	n/M (%/SD)	n/M (%/SD)	n/M (%/SD)	n/M (%/SD)	F/χ 2/V
Demographics
Maternal age at delivery	33.6b (4.35)	35.24a (4.38)	33.52b (3.92)	32.85b (3.53)	8.56 ***
Not married/domestic partnership	11 (5.73)	7 (4.73)	33 (4.44)	1 (1.61)	0.04
Education < bachelor's degree	32 (16.67)	22 (14.86)	81 (10.89)	4 (6.45)	0.08 +
Household income < $100,000	50 (26.04)	29 (19.59)	147 (19.76)	10 (16.13)	4.65
Hispanic	28 (14.58)	17 (11.49)	81 (10.89)	5 (8.06)	0.04
Black or African American	10 (5.21)	10 (6.76)	36 (4.84)	2 (3.23)	0.05
Mental health
Trauma history	134 (69.79)	100 (67.57)	484 (65.05)	41 (66.13)	1.67
Antepartum depression α	9 (4.95)	4 (2.94)	20 (2.92)	1 (1.64)	0.05
Antepartum PTSD α	10b (5.99)	7b (5.38)	15a (2.31)	4b (7.27)	0.10 *
Obstetrics
Primiparity	95a (49.48)	35b (23.65)	269c (36.16)	41a (66.13)	45.32 ***
Gestational age	39.3a,b (1.67)	38.95a (1.5)	39.5b (1.31)	39.47b (1.22)	6.6 ***
Labor induction	92b (47.92)	8a (5.41)	319b (42.88)	34b (54.84)	87.31 ***
Epidural	153b (79.69)	57a (38.51)	601b (80.78)	55b (88.71)	128.57 ***
Complications, labor, and delivery
Mild	79b (41.15)	33a (22.30)	73c (9.81)	7a,c (11.29)	112.2 ***
Moderate	104b (54.17)	18a (12.16)	75a (10.08)	31b (50)	227.28 ***
Severe	1 (0.52)	1 (0.68)	1 (0.13)	0	0.04

Note: Unscheduled cesarean delivery (CD) = unscheduled (n = 167) and emergent (n = 25) CD; trauma history = number of traumatic events “happened to me” using the Life Event Checklist for DSM‐5 (LEC‐5); depression, pregnancy = Edinburgh Postnatal Depression Scale (EPDS ≥13) indicating probable depression; PTSD, pregnancy = Post‐Traumatic Stress Disorder Checklist for DSM‐5 (PCL‐5 ≥32) indicating probable PTSD; epidural for scheduled cesarean delivery includes epidural or combined spinal‐epidural; obstetric complications = mild (i.e., short‐term complications), moderate (i.e., significant morbidity or long‐term risk), and severe (i.e., life threatening conditions). The highest complication severity was counted for participants with more than one complication. Means and counts with different superscript letters are significantly different at p < 0.1 based on Sidak adjustment. For categorical variables with participants counts less than 5, Fisher's exact test was applied, and Cramer's V was calculated to quantify effect size. Missing information on demographics (age, marital status, education, and income), mental health (trauma history, and antepartum depression and PTSD) and obstetric information (primiparity) were handeled using data imputation.

Abbreviation: PTSD, posttraumatic stress disorder.

^α Missing responses corrected only for individual items, hence n is smaller.

^* p < 0.05.

^** p < 0.01.

^*** p < 0.001.

⁺ p < 0.1.

At the immediate postpartum assessment (∼31 hours postpartum), 10.5% (n = 120) of the sample reported clinical stress (PDI ≥15) occurring during childbirth or immediately after. At the later time point (∼1.9 months postpartum), 9.6% (n = 76) continued to meet this threshold. Stress responses were associated with the obstetric complications severity (ρ = 0.28, p < 0.001) (Table S1).

4.1. Acute stress reactions to childbirth and delivery mode

Among participants who underwent unscheduled CD, 26.6% endorsed clinically significant acute stress reactions. Rates varied by stage of labor during which the unscheduled CD was performed: 14.3% when non‐laboring (5/35), 25.3% in the first stage (23/91), and 34.9% during the second stage (23/66) (Table 2). Rates were higher for unscheduled CD during laboring in comparison to non‐laboring (χ²(1) = 3.31, p = 0.07) and stress levels were associated with obstetric complications severity, ρ = 0.20, p = 0.005 (20.3% and 33.7% in patients with minor and moderate complications, respectively). In contrast, acute stress rates were 6.3% among participants with vaginal delivery and 22.6% in assisted vaginal delivery (28.6% and 29.0% in minor and moderate obstetric complications) (Table 3).

TABLE 2.

Acute stress response by labor stage and obstetric morbidity in unscheduled cesarean delivery.

	Complication severity	Acute stress (PDI ≥15)
Labor stage		n (%)
Non‐laboring	None	0
	Mild	3 (15.79)
	Moderate	2 (14.29)
	Severe	‐
First stage	None	0
	Mild	4 (14.29)
	Moderate	19 (33.33)
	Severe	‐
Second stage	None	‐
	Mild	9 (28.13)
	Moderate	14 (42.42)
	Severe	0

Note: Acute stress reactions to recent childbirth measured in the immediate postpartum (∼31 h) using the Peritraumatic Distress Inventory (PDI), clinical cutoff (≥15); labor stages during performance of unscheduled cesarean delivery = non‐laboring (n = 35): prior to initiation of contractions (e.g., PROM non‐vertex/non‐TOLAC candidate, newly diagnosed macrosomia, etc.) and laboring with regard to the stages of labor; first stage (n = 91): from onset of labor to full cervical dilation; and second stage (n = 66): full dilation to fetal delivery; obstetric complications severity = mild: short‐term complications; moderate: significant morbidity or long‐term risk, including infant health complications; and severe: life‐threatening conditions. For multiple complications, the highest severity of complication was counted. n = 192.

TABLE 3.

Acute stress response by delivery mode and obstetric morbidity.

Delivery mode	Complication severity	Acute stress
		M	SD	Range	PDI ≥15
					n (%)
Unscheduled cesarean	None	1.88	3	[0–8]	0
	Mild	8.56	6.97	[0–24]	16 (20.25)
	Moderate	11.37	9.65	[0–44]	35 (33.65)
	Severe	‐	‐	[14]	0
Scheduled cesarean	None	3.65	4.72	[0–26]	3 (3.13)
	Mild	4	3.94	[0–14]	0
	Moderate	8.78	8.04	[0–27]	5 (27.78)
	Severe	‐	‐	[11]	0
Vaginal	None	4.65	4.97	[0–30]	31 (5.21)
	Mild	4.93	5.31	[0–26]	6 (8.22)
	Moderate	8.35	7	[0–39]	10 (13.33)
	Severe	‐	‐	[12]	0
Assisted vaginal	None	7.96	8.54	[0–37]	3 (12.50)
	Mild	6.71	6.45	[0–15]	2 (28.57)
	Moderate	10.97	10.01	[0–37]	9 (29.03)
	Severe	‐	‐	‐	‐

Note: Acute stress pertains to reactions during or immediately after childbirth measured in the immediate postpartum (∼31 h) using the Peritraumatic Distress Inventory (PDI) clinical cutoff (≥15); delivery modes: unscheduled cesarean = unscheduled (n = 167) and emergent (n = 25) cesarean delivery; scheduled cesarean delivery (n = 148); vaginal delivery (n = 744); and assisted vaginal delivery (n = 62). Obstetric complications severity = mild: short‐term complications; moderate: significant morbidity or long‐term risk, including infant health complications; and severe: life‐threatening conditions. For multiple complications, only the highest severity of complication was counted.

Table 4 presents the risk for acute stress by delivery mode. The rate of clinically significant acute stress was higher in response to unscheduled CD, compared to other modes (excluding assisted vaginal delivery) (χ²(3) = 80.47, p < 0.001). At the immediate postpartum assessment, the relative risk (RR) of acute stress in unscheduled CD, compared to vaginal delivery, was 4.20 (confidence interval [CI], 2.92–6.05). Accounting for contributors associated with acute stress levels (p ≤ 0.10) (i.e., time interval between delivery and PDI completion, maternal age, education, income, primiparity, antenatal depression/PTSD, induction, and obstetric complications), aRR was 2.60 (CI, 1.59–4.24). The unscheduled CD group also had higher risk for acute stress compared to scheduled CD (RR = 4.91; CI, 2.41–10.03; aRR = 3.25; CI, 1.37–7.72).

TABLE 4.

Acute stress responses to childbirth by mode of delivery.

	Acute stress
Mode of delivery	Acute stress (PDI ≥15), n (%)	χ2	Relative risk [95% CI]	M	SD	Range
Unscheduled cesarean	51 (26.56)	80.47 ***	Reference	9.83	8.66	[0–44]
Scheduled cesarean	8 (5.41)		4.91 *** [2.41–10.03]	4.40	5.32	[0–27]
			3.25 ** [1.37–7.72] a
Vaginal	47 (6.32)		4.20 *** [2.92–6.05]	5.06	5.35	[0–39]
			2.60 *** [1.59–4.24] a
Assisted vaginal	14 (22.58)		1.25 [0.65–2.41]	9.32	9.15	[0–37]
			1.19 [0.73–1.94] a

Note: Participants assessment completed ∼31 h after childbirth (n = 1146). Stress response measured using the Peritraumatic Distress Inventory (PDI) clinical cutoff ≥15 using unscheduled cesarean delivery (CD) as a reference group. Unscheduled CD = unscheduled (n = 167) and emergent (n = 25) CD; scheduled CD (n = 148); vaginal delivery (n = 744); and assisted vaginal delivery (n = 62).

Abbreviations: CI, confidence interval; PTSD, posttraumatic stress disorder.

^a Adjusted relative risk in reference to unscheduled CD accounting for maternal age, education, income, trauma history, antepartum depression and PTSD, primiparity, labor induction, and obstetric complications.

^* p < 0.05.

^** p < 0.01.

^*** p < 0.001.

⁺ p < 0.1.

Commonly endorsed acute stress items for women who had unscheduled CD included having physical stress reactions (64.6%), feeling helpless (37%),  feeling they might pass out (37%), and thinking they might die (14.6%) (Figure 1).

FIGURE 1.

Characteristics of acute stress responses to childbirth by mode of delivery. The histogram bars represent the percentage of participants by delivery mode with endorsement of a score of 2 or higher (i.e., at least a moderate degree) on each of the 12 items of the Peritraumatic Distress Inventory (PDI), excluding item 4. Assessment obtained ∼31 h after childbirth. n = 1146.

4.2. Stability of acute stress and delivery mode

Figure 2 presents acute stress levels in response to childbirth by delivery mode assessed across time points (model fit, marginal R ² = 0.22; conditional R ² = 0.73). Significant fixed effects were observed for delivery mode (F(3, 661) = 12.77, p < 0.001) and for the interaction (delivery by time) (F (3, 671) = 3.47, p = 0.02). The time effect was not significant (F(1, 671) = 0.45, p = 0.50).

FIGURE 2.

Level of acute stress to childbirth over time by delivery mode. The figure depicts stress levels in response to recent childbirth assessed by the Peritraumatic Distress Inventory (PDI) (total score) for each delivery mode in the immediate postpartum assessment (∼29.4 h post‐delivery) time point and the second (∼1.9 months post‐delivery) assessment. n = 795.

The unscheduled CD had higher stress (PDI score) across time points in comparison to vaginal delivery (estimate = 3.84, p < 0.001) and scheduled CD (estimate = 3.94, p < 0.001) but not assisted vaginal delivery (estimate = 0.81, p = 0.83). While stress levels were stable for the unscheduled CD (estimate = 0.39, p = 0.44) and assisted vaginal delivery (estimate = 0.34, p = 0.68), the levels decreased for vaginal delivery (estimate = 0.52, p = 0.03) and increased for scheduled CD (estimate = 1.33, p = 0.01), accounting for contributing factors.

4.3. Acute stress as a risk factor for later mental health problems

Regression analyses revealed that acute stress reported immediately postpartum significantly predicted mental health and maternal–infant bonding outcomes around two months later. Accounting for obstetric factors (i.e., delivery mode, complications severity, primiparity, epidural use, and labor induction), acute stress levels predicted childbirth‐related PTSD symptoms (β = 0.48, p < 0.001, R ²‐change, ΔR ² = 0.19), depressive symptoms (β = 0.30, p < 0.001, ΔR ² = 0.09), and bonding difficulties (β = 0.32, p < 0.001, ΔR ² = 0.08). When applying Holm–Bonferroni adjustment to account for multiple analyses, results remained significant (p < 0.017, Holm‐adjusted).

5. DISCUSSION

5.1. Principal findings

The reported study documents high rates of psychological stress among patients who underwent unscheduled CD, most of whom experienced non‐emergent procedures. A total of 26.6% of unscheduled CD patients reported clinically significant acute stress reactions occurring during childbirth or immediately after with higher rates related to stages of labor (29.3% in CD performed in labor) and obstetric morbidity. The risk of endorsing acute stress was approximately three times higher for patients undergoing unscheduled CD, compared to those with vaginal delivery, after accounting for factors including demographic background, primiparity, obstetric complications, labor induction, antepartum mental health status, and trauma history. Reported heightened traumatic stress among women with unscheduled CD persisted through the early postpartum months, while those who had vaginal delivery exhibited low stress levels that further declined over time. Acute stress during childbirth predicted subsequent PTSD and depressive symptoms and maternal–infant bonding problems. These findings demonstrate that unscheduled CD may signal increased vulnerability to psychological stress during childbirth and heightened stress may have enduring effects on maternal mental health. Importantly, rates of acute stress were similar between women undergoing unscheduled CD and those with assisted vaginal delivery, suggesting that underlying obstetric acuity, the need for an unanticipated intervention, or morbidity might be associated with stress responses, rather than the procedure itself.

5.2. Results in the context of what is known

There is growing recognition of childbirth as an experience that can be psychologically stressful for some individuals [57, 58, 59, 60]. Prior studies have shown that unscheduled CD is associated with an increased risk of developing PTSD symptoms [36, 61, 62, 63, 64]. Yet, there remains a limited understanding of the immediate psychological impact of unscheduled CD. This study documents significant stress reactions during childbirth in women who undergo unscheduled CD. These immediate reactions are clinically meaningful, as they may serve as early indicators of subsequent maternal posttraumatic and depressive symptoms and maternal–infant bonding problems. The pattern of clinically significant stress we observed closely mirrors immediate psychological responses reported in individuals exposed to other traumas [26, 27, 28, 29, 30, 31].

5.3. Clinical implications

While the first 24 hours after childbirth is well recognized as a critical window for monitoring physical recovery [54, 65, 66, 67, 68], especially after CD [69], the psychological contribution of the mode of delivery has received limited attention in clinical practice and maternity care planning. This study demonstrates that unscheduled CD associates with heightened psychological stress reactions during this important period of maternal behavior initiation. Because peritraumatic reaction can serve as a risk factor for posttraumatic mental health conditions [25, 32, 33, 41], timely screening for acute stress responses immediately following unscheduled CD or other medically complicated deliveries with unanticipated interventions, such as cases of assisted vaginal delivery, would improve the accuracy of mental health determinations, enhance opportunities for early and effective treatment [70], and better prepare patients for future pregnancies [24, 41, 70].

Currently, US hospital screening protocols focus on maternal depression (e.g., using the EPDS) and do not assess traumatic stress. Our findings support the ACOG recommendation for more comprehensive mental health screening [71]. Importantly, our findings highlight the potential of the PDI as a brief, scalable screening tool that can be administered during maternity hospitalization stay to identify women at elevated risk for PTSD or other adverse psychological outcomes after complicated or traumatic deliveries [41]. Anticipating risk for traumatization during pregnancy may inform shared decision‐making around birth plans and delivery mode and optimize maternal and neonatal outcomes [72].

Unscheduled CD may disrupt oxytocin and cortisol surges that support labor [73, 74]. Dysregulated stress responses in combination with the threat of undergoing an unplanned major obstetric procedure and its acuity may increase susceptibility to traumatization. Acute stress reactions were higher among women who underwent unscheduled CD after labor had already started, compared to those who had unscheduled CD before labor began or scheduled CD. We also found that acute stress was associated with the degree of obstetric complications, suggesting a dose–response relationship between obstetric morbidity and acute stress. Thus, the disruption of naturally occurring maternal‐stress regulation during labor and/or the events leading to the surgery may intensify acute stress response. Our findings also point to the direction of considering the unanticipated obstetric intervention rather than merely the mode of delivery in triggering maternal distress potentially via increased sense of loss of control.

5.4. Research implications

An important direction for future research is the development of comprehensive risk assessment models that integrate obstetric factors commonly associated with unscheduled CD, such as labor induction, pain intensity, epidural use, time of birth, and maternal or neonatal complications, alongside pre‐existing psychological vulnerabilities. Given that the subjective childbirth experience plays a key role in posttraumatic maternal outcomes [75, 76], future studies are needed to investigate the role of a support person, staff support, and patient–clinician interactions in shaping trauma responses. Understanding how these interpersonal and contextual factors amplify or buffer distress will be essential for developing evidence‐based recommendations for trauma‐informed care in the wake of unanticipated obstetric interventions beyond unscheduled CD. Gaining insight into the potential for psychological growth following a traumatic childbirth as well as the processes facilitating meaning‐making may provide pathways for maternal resilience [77, 78, 79, 80]. More research is needed to understand the potential psychophysiological pathways underlying stress responses and medically complicated deliveries, including a comprehensive assessment of obstetrical factors that may amplify these responses. As heightened stress during labor can lead to sympathetic dominance that may impact uterine contractions and impede labor progress, increasing unscheduled CD risk [4, 5], examination of the bi‐directional relationship between stress and medically complicated deliveries is warranted.

5.5. Strengths and limitations

A key strength of this study is the ability to assess patients’ stress reactions to childbirth during the immediate postpartum period. We used a well‐established structured instrument to measure traumatic stress, previously validated in trauma‐exposed populations, to capture clinically significant acute reactions to childbirth. Rather than relying on a community sample, the study was performed in a clinical setting to estimate rates of stress reaction. We conducted repeated assessments to evaluate the stability of recalled stress reactions and their association with postpartum mental health. The risk of acute stress associated with unscheduled CD was compared to other delivery modes. We incorporated electronic medical record data to assess obstetric complications, labor induction, and important antepartum mental health status and prior trauma, which allowed more nuanced and adjusted analysis of unscheduled CD's link with traumatic stress.

Several limitations should be noted. The study design does not permit causality or the separation of the contribution of stressful or acute events leading to unscheduled CD from the contribution of the procedure itself to acute stress responses. While we accounted for obstetric complications, it is not possible to know whether it is the unscheduled CD, the indication for the unscheduled CD, or the unexpected nature of having a serious medical procedure that is associated with increased acute stress responses compared to vaginal delivery. There could have been differences between the two reported cohorts on other background factors beyond those reported, as well as differences in obstetric practice. Women experiencing severe stress were potentially less likely to be approached and, therefore maybe less represented in the study sample. We did not include biological measures of acute stress (e.g., heart rate variability), which could have provided mechanistic insights. Finally, although the obstetric characteristics of participants who completed both assessments were generally representative of the original cohort, there were differences between completers and non‐completers on some demographic characteristics. As a significant proportion of study participants were lost to follow‐up, potentially due to assessments performed during the demanding first postpartum months, monetary incentives, and remote engagement, this should be taken into account in findings’ interpretation. Cultural or sociodemographic differences may limit the generalizability of our findings to other populations or healthcare systems.

6. CONCLUSIONS

Unscheduled CD can be lifesaving for both mother and fetus. Our findings provide evidence for an associated increased risk of psychological traumatization among patients who undergo unscheduled CD, with consequences for maternal mental health. Given that trauma exposure and stress can lead to profound neurobiological changes [79, 80, 81], and heighten vulnerability to re‐traumatization with subsequent traumatic events [33, 82, 83], there is a need to prioritize birth trauma prevention in perinatal care after obstetrical acuity, especially those entailing unanticipated interventions. Patient and provider education is an essential first step that should facilitate implementation of trauma‐informed screening, early intervention strategies, and systemic policy reforms.

6.1. Declaration of generative AI and AI‐assisted technologies in the writing process

During the preparation of this work, the authors used ChatGPT‐4o in order to improve language and readability and reduce word count. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

CONFLICT OF INTEREST STATEMENT

Andrea G. Edlow reports consulting fees from Mirvie, Inc and Merck, Sharpe and Dohme, and research funding from Merck, Sharp and Dohme, all outside of this work. All other authors declare no conflicts of interest.

Supporting information

Supporting Information

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.