**1. Introduction**

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that may occur to a person who has experienced or witnessed a traumatic event such as a natural disaster, a serious accident, sexual violence, threatened death or death, serious injury, or extreme repeated exposure to the workplace [1]. PTSD has been known by other names in the past, such as "shell shock" during the World War I and "combat fatigue" after World War II. PTSD can happen in all people of any nationality or culture and at any age [2]. However, the prevalence of PTSD is about 10–12% in women and 5–6% in men [3], and this shows how it is influenced by traumatic birth experiences, hormonal disorders, stressful life events, and domestic violence [4]. PTSD is diagnosed after a month of a traumatic event and characterized by four main types of symptoms: re-experiencing, avoidance, negative thoughts and feelings, and arousal [5].

On the other hand, partial or profile PTSD involves many PTSD symptoms but not all, since persons exposed to the traumatic event do not meet all PTSD criteria. This is PTSD profile, which has been shown to be associated with high rates of suicidal

ideation, alcoholism, absence in the working environment, and overconsumption of health services [6, 7].

#### **1.1 Postpartum PTSD (P-PTSD)**

For several years, the birth experience was considered by scientists as a positive experience for the woman. In recent years, however, research into birth trauma has increased interest, and it is now known that one out of three women had a stressful childbirth experience [8], while approximately 6% of women will develop acute PTSD and up to 16% clinically significant PTSD symptoms [9].

A traumatic birth experience can affect to a significant extend the woman herself and her family. Actually, P-PTSD may impair a mother-child bond and has an indirect adverse effect on the newborn's health. Also, P-PTSD or PTSD profile can overshadow the relationship with the partner and the desire to acquire another child in the future [10].

P-PTSD is the outcome of interaction between pre-labor, intrapartum, and postpartum vulnerability factors [11]. Various conditions seem to affect the development of this disorder, such as pregnancy pathology, complications during birth, emergency cesarean section, personal history of psychiatric disorders, fear of childbirth, and previous traumatic events in the mother's life [12–15]. Past traumatic life events may lead to a new PTSD after a traumatic birth experience. For explanation, the past traumas can be recalled and cause posttraumatic symptoms of an old PTSD [12, 13, 16].

Comorbidity of P-PTSD and depression is a very common phenomenon as evident in up to 70% of postpartum women endorsing P-PTSD [17]. Furthermore, suicidal ideation prevails in about 20% of women with P-PTSD [9], and for this reason, this postpartum mental disorder deserves more attention.

#### **1.2 P-PTSD after cesarean delivery**

The type of delivery and the P-PTSD was the subject of research by several researchers [10, 18, 19]. Regarding cesarean sections (CSs), however, there are studies that do not differentiate the outcome between emergency cesarean section (EMCS) and elective cesarean section (ELCS), and they finally consider that there is no connection between EMCS and PTSD [20–23]. On the other hand, there are many surveys that support a strong relationship between P-PTSD and EMCS in contrast to other kinds of delivery [16, 24–26]. So far, only two surveys investigate the correlation between EMCS and P-PTSD. A study published in 1997 was the first one showing that the majority of women experienced EMCS as a mental trauma [27], as well as a following article, that investigated the P-PTSD symptoms 3 months postpartum [27]. An explanation for this correlation is that the EMCS could be an unexpected outcome for some women who going through a difficult vaginal delivery were rushed into the operating room and underwent surgery with spinal/epidural anesthesia and in some cases, general anesthesia [28]. Furthermore, some studies also identified that past traumatic life events, low social support, poor coping skills, and psychiatric history are more determining factors for the development of P-PTSD [11, 13, 29].

#### **1.3 P-PTSD after cesarean delivery in Greece**

In Greece during 2019, there were about 85.000 [30], of which more than 50% were CS [31]. As a result, Greece occupies one of the greater positions worldwide [32]. *Cesarean Delivery and Mental Health DOI: http://dx.doi.org/10.5772/intechopen.108847*

Apart from Greece, other countries such as Turkey, Mexico, Chile, Korea, Poland, and Hungary have been in the top positions in the world [33], which shows that the mothers of these countries are more exposed to birth trauma and consequently, more likely to develop P-PTSD or other mental disorder of postpartum period. So far, no research has been carried out in Greek women on P-PTSD or PTSD Profile, while the data are limited to other medical disorders of the postpartum period, such as depression [34, 35]. Therefore, this is the first survey that investigates P-PTSD in Greek women and specifically in a group of women who are more exposed to birth trauma. The purpose of this investigation is first to study the frequency of P-PTSD between two groups of women (EMCS and ELCS) in the sixth week postpartum and secondly to determine the risk factors and their degree of contribution to the development of P-PTSD and PTSD Profile. After identifying the risk factors, it is expected to develop specialized midwifery interventions and treatment in women with P-PTSD. This survey should signal the start of further investigations in the P-PTSD in Greece.
