**4. Discussion**

The aim of this survey was to identify perinatal and predisposing factors during cesarean delivery that help the development of PTSD or PTSD Profile in postpartum period, in order to realize appropriate preventive interventions in perinatal care. Our findings show that 40% of mothers reported their cesarean delivery as a traumatic event, while the Criterion A met by a quarter of all deliveries. Moreover, we found that postpartum PTSD was associated with preterm birth, inclusion in NICU, lack of breastfeeding, EMCS, and lack of support from a partner.

Several previous studies were considered the emergency cesarean delivery as a major risk factor for postpartum mental illness, such as depression [45–47] and PTSD [27, 48]. For example, the Schwab et al. study shows that all women who had been diagnosed with postpartum PTSD had undergone an EMCS [16]. The systematic review of Benton et al. found an association between EMCS and psychological outcomes in mothers with particular postpartum PTSD [49]. In addition, the Modaress et al. study found high levels of PTSD in women who underwent an EMCS in contrast to ELCS and those with vaginal delivery [50]. Furthermore, the findings of Ryding et al. investigation for PTSD reaction in women who underwent an EMCS showed that 1/3 of the sample suffered from serious PTSD reactions [48]. On the contrary, the study by Lopez et al. found no association between PTSD and a kind of CS, but with anesthesia complications [23]. Also, a systematic review of Futura et al. found a relationship with preeclampsia, rather than the type of CS [51].

However, the present study found that 13.1% of the population met the DSM-5 criteria for postpartum PTSD (31.7% after EMCS and 1% after ELCS), while 8.1% of women were suffering from Profile PTSD according to DSM-5 (**Table 3**). A possible explanation for the high difference in prevalence among two groups of mothers is due to the emergency surgery. Since, emergency surgery is unexpected more often with the pathology of gestation [50, 52], and can be a midwifery predictor of the development of postpartum PTSD [8, 27]. Therefore, the increase in EMCS increase PTSD, while an important reason for this phenomenon might be that the induction of labor takes place before the 41st week of gestation [53, 54].

An observation must be made regarding ours and other research findings. This survey is the first to investigate the evolvement of PTSD Profile and PTSD in postpartum women after EMCS or ELCS. In addition, it is one of the few articles where they used all the diagnostic criteria for PTSD postpartum, according to the DSM-5 (**Table 3**) [13], and this increases the sensitivity of the PCL-5 compared with common investigations in the past. So far, the fifth version of the PCL has not been in used in Greece yet. This is the first survey that used the PCL-5 in the Greek population and especially in postpartum women.

The findings of our study indicated that a preterm labor is associated with PTSD. From the survey participants, only 76.2% women after EMCS and 87.6% after ELCS had a full-term labor, and 1/3 of women who met the diagnostic criteria for PTSD or PTSD Profile had given birth prematurely. Only a few studies in the past have reported that a preterm delivery was a risk factor for PPTSD and other postpartum mental health disorders [55–57], and our study agrees with them. One hypothesis is that prematurity is related to emergency situations, neonatal complications, and inclusion in the NICU. Therefore, the risk of losing an infants' life is real (the adapted for the present research criterion A) and the cause of the development of postpartum mental health trauma.

In addition, another very important risk factor related to the previous one for the development of postpartum PTSD is the inclusion of the neonate in the NICU. It seems that the separation of the mother from the infant due to the admission to NICU is associated with a birth of a preterm neonate, pathology of gestation, and EMCS as well. It is already known that the postpartum distress after the admission of the neonate in the NICU consists of a complication of depressive, anxiety, and PTSD symptoms and is linked negatively with maternal-infant attachment [56, 58]. In our

#### *Cesarean Delivery and Mental Health DOI: http://dx.doi.org/10.5772/intechopen.108847*

findings, inclusion in the NICU is related to 11.3% of ELCS and 30.2% of EMCS and includes preterm and full-term neonates.

For a large percentage of women, breastfeeding is an extension of the birth experience, and it has been proven that it can reduce the birth trauma. In some cases, breastfeeding after a traumatic childbirth experience can be disappointing due to traumatic reminders of childbirth. All these feelings, as a part of avoidance symptoms of PTSD (Criterion C) [36], can lead to a lack of initiation or premature termination of breastfeeding [59]. In this survey, the lack of breastfeeding played an important role in the development of the birth trauma caused to the woman by the cesarean delivery, with rates of 95% in the first 24 h breastfeeding mothers without PTSD and 4.5% in breastfeeding mothers with PTSD. Therefore, breastfeeding is a relief by increasing the mental resistance of mothers exposed to birth trauma. These results are similar with the Hoff et al. study, which investigates that the lack of breastfeeding affects the development of the mother-child attachment and contributes to the intensity of the distress of the mother and developing postpartum PTSD [60]. Actually, in the Maureen et al. study, breastfeeding mothers had a lower perceived stress, lower depression and anger, and reported more positive life events than from postnatal PTSD [61–63].

Unfortunately, in Greece, there are few psychoeducation supporting services for women exposed to birth trauma. Among the few perinatal centers, Fainareti [64] is the first public perinatal center, which provides psychoeducation to mothers and couples. Due to this great lack of perinatal centers, support from a partner or spouse is one of the main factors protecting from postnatal PTSD.
