**3. Risk factors for the onset of postpartum stress disorder and its frequency**

It is significant to determine the definition of a "healthy or normal" childbirth. Medical model suggests it is a childbirth with no death occurrences, one without any medical interventions but also one where the mother, her wishes, and attitudes are

#### *Postpartum Posttraumatic Stress Disorder DOI: http://dx.doi.org/10.5772/intechopen.114052*

appreciated. Childbirth is an extreme physical and psychological experience in the life of a woman, one which they can perceive either as a mild stress or a traumatic experience, depending on many factors. It differs from other potentially traumatic experiences because it is an occurrence a woman voluntarily goes through, and is a predictable, in most cases positive experience.

A number of factors can be linked to the onset of postpartum PTSD. As with PTSD after any other traumatic experience, risk factors for its occurrence can be classified in several ways: pre-traumatic (vulnerability factors and pregnancy itself), those related to the immediate effect of trauma (childbirth), and post-traumatic factors. Risk factors can also be classified into three groups: biological, psychological, and social. The specifics of risk factors for postpartum PTSD refer to the physiological changes that occur during childbirth, the circumstances in which childbirth takes place (most often hospital conditions), but also the active role of partners and health workers in the child-birthing process.

Risk factors that exist in the period before the traumatic experience are lower socioeconomic status of a pregnant woman and lower level of education, treatment of infertility, unwanted pregnancy, and previous traumatic experiences related to childbirth, as well as a history of psychological disorders (e.g. depression and PTSD) [9, 10]. Certain personality traits (neuroticism) can also be a risk factor for the onset of postpartum PTSD, as well as increased sensitivity to anxiety [11]. A history of sexual abuse, primarily in childhood, as well as pregnancies resulting from sexual abuse, are also pre-traumatic risk factors.

Factors present at the time of childbirth are as follows: stillborn child, spontaneous miscarriage, premature labor, or perinatal loss. The ending of childbirth, experienced pain, and social support during childbirth are also peritraumatic risk factors [9]. Obstetrical complications, such as vacuum extraction of the child, instrumental birth, emergency cesarean section, etc., are significant factors that can lead to PTSD.

The most stressful way of delivery for a woman is an instrumental vaginal labor, after that, an emergency cesarean section and normal vaginal labor, and the least stressful of all is planned cesarean section [11, 12]. The length of delivery and loss of blood during the entire event can be risk factors for postpartum PTSD. The feeling of having control over the delivery is something that can prevent the onset of PTSD, whether it's external control (over what other people are doing, the involvement of the mother in decision-making and sufficient level of information) or internal control (control over one's body and behavior).

Postpartum risk factors are inadequate social support (healthcare, support from a partner or family), newborn's temporary stay in intensive care units, additional traumatization, etc.

It is a known fact that postpartum PTSD can occur both after complicated and non-complicated deliveries, and it can even occur in women that had a "normal" vaginal delivery (delivery at expected time, with a healthy newborn). The subjective experience of childbirth itself is of key importance for the occurrence of posttraumatic stress disorder. Even when, medically speaking, neither women nor babies are in immediate life threat, some women will experience childbirth as a traumatic experience and later develop symptoms of PTSD.

Our study, which included 150 primiparous women that had a vaginal delivery, showed that there was no difference between the group of mothers with PTSD symptoms and those without symptoms in terms of sociodemographic characteristics and general clinical characteristics. The most important finding was that the group of mothers with PTSD symptoms had significantly more frequent obstetric

interventions (vacuum extraction, forceps extraction) and pelvic presentation during labor [13]. However, it is still not known which biological and psychological factors are the most significant for the development of postpartum PTSD. Parameters of sympathetic activity (pulse and blood pressure) and serum cortisol concentration are mentioned in the literature as possible biological factors. In our study, we found no significant difference between pregnant women without symptoms and those with symptoms of postpartum PTSD in terms of body weight, systolic or diastolic blood pressure, or heart rate measured immediately after delivery (trauma) [13].

According to currently available literature, the prevalence of postpartum PTSD is from 3.1 to 4.7% [14]. It is important to point out that individual symptoms of this disorder can be noticed in a significantly larger number of women in labor, from 1.5 to even 33.1%. In our study, the prevalence of PTSD associated with childbirth was 2.4%, while 11.9% of women who have recently given birth had some symptoms of this disorder 1 month after childbirth [13]. The varying frequency of disorders in literature is a consequence of methodological inconsistencies. When the assessment was performed closer to the time of delivery, the frequency of disorders was higher. In accordance with the well-known fact of spontaneous recovery after a person's exposure to a traumatic experience of any kind, it has been shown that the prevalence of postpartum PTSD decreases as time passes after childbirth and that the clinical picture is then milder in intensity [13, 15]. If all of the above is taken into account it can be expected that a very small number of women will develop symptoms of chronic postpartum PTSD after giving birth. It is also known that the partners of women giving birth can also develop symptoms of postpartum PTSD, and according to some estimates, the prevalence is 1.2% [16].
