Analysis of Intrathecal Labor Analgesia and the Causes of Maternal Postpartum Depression After Cesarean Section

doi:10.21203/rs.3.rs-5216530/v1

BACKGROUND: Postpartum depression (PPD) is a common complication after childbirth, and its etiology may be related to several factors. In this study, we investigated the prevalence and causes of PPD in women who underwent vaginal delivery with intrathecal labor analgesia and women who underwent cesarean section.

METHODS: A total of 242 women who gave birth from July 2022to July 2023 participated in this retrospective case‒control study, including 127 women who underwent cesarean section and 115 women who underwent vaginal delivery and received intrathecal labor analgesia. The clinical data of the study participants were collected, and anxiety, depression and PPD were assessed by the Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS) and the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS); questionnaires were administered and telephone follow-up was conducted on the first day of the antenatal period. The Chinese version of the EPDS was used to assess maternal psychological status at 6 weeks after delivery, and an EPDS score ≥10 points at 6 weeks after delivery was used as an indicator of PPD. The related factors affecting the occurrence of PPD were analyzed by one-way analysis, and the independent risk factors affecting the occurrence of PPD were analyzed by multifactorial logistic regression.

RESULTS: The incidence of PPD was approximately 5.0% (12/242) in the women who underwent vaginal delivery and received intrathecal labor analgesia and 11.1% (27/242) in those who underwent cesarean section. Multifactorial logistic regression analysis showed that advanced maternal age was a risk factor for PPD (odds ratio [OR], 1.31, 95% confidence interval [95% CI], 1.04-1.66; P=0.02); prenatal anxiety (OR: 8.48, 95% CI: 2.73-26.27; P=0.02) and depression (OR: 10.99, 95% CI: 2.18-55.37; P<0.001) were also risk factors for PPD. A second birth was a protective factor against PPD (OR: 0.09, 95% CI: 0.01-0.57, P<0.05).

CONCLUSION: Advanced maternal age and prenatal anxiety and depression were associated with the development of PPD in women who underwent vaginal delivery with intrathecal labor analgesia and those who underwent cesarean section. Obstetricians and gynecologists can identify mothers at high risk of PPD at an early stage and provide psychological counseling for mothers to reduce the incidence of PPD. However, studies with large sample sizes are still needed.

PPD

Intrathecal Labor Analgesia

Cesarean Section

Causes

Edinburgh Postnatal Depression Scale

Postpartum depression (PPD) is defined as mild or severe depressive episodes in the first 12 months after childbirth. Pregnancy and childbirth cause many physical and psychological changes in women, and women are the most vulnerable to depression during this period^[1–3]. PPD often occurs in the first 4–6 weeks after birth and affects not only maternal and infant health but also family relationships.^[4] Other studies have shown that PPD affects not only breastfeeding but also infant behavior^{[5, 6]}. Mothers with depression are less likely to touch their babies, are less able to meet their babies’ developmental needs^[7] and have infants who develop more emotional problems^[8]. The prevalence of PPD in Western countries is reported to be 13–19%^[9]. The prevalence of PPD in Chinese women is 10–15%^[10].

The pain associated with childbirth is the worst pain experienced by most women in their lives, and intrathecal labor analgesia, which includes epidural and combined spinal and epidural analgesia, is the most commonly used method for relieving women's pain during childbirth; intrathecal analgesia does not increase the rate of cesarean section and is effective at relieving the pain associated with childbirth^[11]. PPD is associated with several factors, and the aim of our study was to investigate the incidence and causes of PPD in women who undergo vaginal delivery with intrathecal labor analgesia and women who undergo cesarean section.

2.1 Research design and ethics

This study follows the Declaration of Helsinki, the study was a retrospective case-control study, and the study protocol was approved by the Ethics Committee of Chaohu Hospital of Anhui Medical University (KYXM202312004) and and has been registered at ClinicalTrials.gov under registration number ChiCTR2400089447 with a registration date of 2024-09‐09 and patient recruitment date of 2024‐01‐05.

2.2 Recruitment of participants

The inclusion criteria for participants were as follows: singleton mothers aged 20–40 years at 37–41 weeks gestation who had a BMI 21–40 kg/m² and had full-term normal labor; women who provided informed consent for the study; women who had good communication skills; and women who had no cardiac, liver or renal dysfunction. Mothers were excluded if they met the following criteria: (1) had a history of mental illness or other serious illnesses; (2) had underlying prepregnancy illnesses; (3) refused to communicate and cooperate; (4) had an abnormal delivery outcome; and (5) had contraindications for intrathecal anesthesia, including infection of the skin at the site of puncture, coagulation disorders, or a history of spinal surgery.Based on the inclusion and exclusion criteria, the maternal screening flowchart is shown in Fig. 1.

2.3 Data collection

Baseline and demographic data were collected through the maternal general information questionnaire by reviewing relevant medical records and verbal questioning and included the following: age, education level, work status, residence status, family economic status, marital status, number of deliveries, mode of delivery, whether the pregnancy was planned or not, whether pregnancy-related diseases occurred, adverse pregnancy and childbirth histories, sleep quality during pregnancy, marital relationship status, relationship with husband's family members, etc. The postpartum data were recorded after the delivery of the baby, the postpartum numerical rating scale (NRS) score was recorded at 24 h, 3 days and 3 months after delivery. The NRS score ranged from 0–10, with 0 indicating no pain and 10 indicating severe pain; the higher the score was, the more intense the pain. Information about the newborns (weight, sex, Apgar score, etc.) was recorded. Anxiety and depression were assessed using the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) 1 day before delivery, and the Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) was used to assess the psychological state of the mothers 6 weeks after delivery. The EPDS is a 10-item questionnaire in which each item is scored from 0–3, and higher scores tend to indicate more severe depressive symptoms. The EPDS has a sensitivity of 86% and a specificity of 73%, and a score of 9/10 is used as a threshold to reduce the number of undetected cases to less than 10%^[12].

2.4 Data analysis

SPSS 22.0 was used for data analysis in this study. Normally distributed data are expressed as the mean ± standard deviation, and an independent sample t test was used for comparisons between two groups. Data that did not conform to a normal distribution are expressed as the median (interquartile range), and a nonparametric test was used for comparisons between two groups. Count data are expressed as percentages, and comparisons between two groups were made using the chi-square test. The grade information is expressed as the median (interquartile range), and for repeated measures information, repeated-measures analysis of variance (ANOVA) was used. Taking an α of 0.05, a difference was considered statistically significant at P < 0.05.

3.1 Maternal PPD status

Of the 242 women who delivered at our hospital, 39 women with an EPDS score ≥ 10 points were diagnosed with PPD, and the prevalence of PPD was 16.1%; 12 women who received intrathecal labor analgesia had PPD, and 27 women who underwent cesarean section had PPD.

3.2 Unifactorial analyses affecting PPD occurrence

1. General information of the mothers

Our statistics on the basic maternal-related conditions are shown in the table below. The mean age of the women in the depressed group was 30.77 ± 4.57 years, the average age of the women in the nondepressed group was 28.97 ± 3.64 years, and the average age of the women in the depressed group was significantly greater than that of the women in the nondepressed group (P < 0.05). Regarding women experiencing labor for the first time, the scores were significantly greater in the depressed group than in the nondepressed group (P < 0.05). The use of no pain medication was significantly lower in the depressed group than in the nondepressed group (P < 0.05). There was a significantly greater incidence of underlying maternal comorbidities during pregnancy in the depressed group than in the nondepressed group (P < 0.05). There were no significant differences in the duration of pregnancy, gestational weight gain, prepregnancy weight, BMI, education level, work status, residential status, family economic status, or surgical history between the depressed group and the nondepressed group (P > 0.05) (Table 1). In conclusion, baseline conditions such as advanced maternal age, first delivery, no use of pain medicine, and the presence of underlying diseases during pregnancy significantly increased the probability of PPD occurrence in the depressed group.

Table 1

*General information about the mothers in the two groups*
norm	Depressed group	Nondepressed group	t/χ²	P
Age (years)	30.77 ± 4.57	28.97 ± 3.64	2.711	^a0.007
Duration of pregnancy (days)	275.77 ± 6.78	275.18 ± 5.90	0.555	^a0.580
Pregnancy weight (kg)	73.59 ± 8.84	73.82 ± 11.14	-0.119	^a0.905
Weight before pregnancy (kg)	58.37 ± 8.86	59.34 ± 10.51	-0.540	^a0.590
BMI	28.28 ± 3.18	28.38 ± 4.08	-0.148	^a0.882
the time of birth (%)
1 fetus	25 (64.1 )	88 (43.3 )	5.661	^b0.017
2 fetuses	14 (35.9 )	115 (56.7 )
educational attainment (%)
junior high school	13 (33.3 )	75 (36.9 )	2/338	^b0.662
congrats! (on passing an exam)	5 (12.8 )	17 (8.4 )
branch (of medicine)	14 (35.9 )	62 (30.5 )
undergraduate (adjective)	6 (15.4 )	45 (22.2)
Postgraduates	1 (2.6 )	4 (2.0 )
Working conditions (%)
Has a stable job	16 (41.0 )	82 (40.4 )	0.052	^b1.0
Unstable work	2 (5.1 )	12 (5.9 )
Unemployed	21 (53.8 )	109 (53.7)
residency status (%)
municipalities	25 (64.1 )	127 (62.6 )	0.127	^b0.938
combining urban and rural areas; sophisticated and many-sided	8 (20.5 )	40 (19.7 )
countryside	6 (15.4 )	36 (17.7 )
household economic level (%)
< 3000	18 (46.2 )	90 (44.3 )	4.403	^b0.111
3000–5000	12 (30.8 )	89 (43.8)
5000–8000	9 (23.1 )	24 (11.8 )
surgical history (%)	11 (28.2 )	72 (35.5 )	0.766	^b0.382
Use of pain medication during labour (%)	8 (20.5 )	107 (52.7 )	13.599	^b<0.001
Underlying diseases during pregnancy (%)	25 (64.1 )	86 (42.4)	6.226	^b0.013
Data are presented as the mean ± standard deviation or n (%).
a: Student’s t test
b: Pearson's chi-squared test

2. Situations related to pregnancy

We statistically analyzed the mothers as follows. The quality of sleep during pregnancy was significantly poorer in the depressed group than in the nondepressed group (p < 0.05). The incidence of adverse maternal history was significantly greater in the depressed group than in the nondepressed group (P < 0.001). In terms of labor pain ratings, labor pain ratings were significantly greater in the depressed group than in the nondepressed group (P < 0.001). The percentage of women with poor relationships with their husbands’ families was significantly greater in the depressed group than in the nondepressed group (P < 0.001). The percentage of women who fed their infants formula was significantly greater in the depressed group than in the nondepressed group (P < 0.001). Other aspects, such as whether the pregnancy was planned, whether artificial insemination was used, couple relationship status, whether expectations were met, whether prenatal education classes were attended, and whether regular obstetric checkups were attended, were not significantly different between the two groups (P > 0.05) (Table 2). In conclusion, poor sleep quality during pregnancy, adverse maternal history, severe labor pain, poor relationships with one’s husband's family, and formula feeding were associated with maternal PPD.

Table 2

*Comparison of pregnant women in the two groups*
norm	Depressed group	Nondepressed group	χ²	P
planned pregnancy(%)	32 (82.1)	169 (83.3)	0.033	^b0.855
artificial insemination(%)	0	10 (4.9)	0.953	^b0.329
Sleep quality during pregnancy(%)
favourable	0	17 (8.4)	15.255	^b0.002
usual	5 (12.8)	60 (29.6)
Occasional insomnia	15 (38.5)	74 (36.5)
Frequent insomnia	19 (48.7)	52 (25.6)
Adverse maternal history(%)	12 (30.8)	11 (5.4)	21.586	^b<0.001
Labour pain score(%)
mild	8 (20.5)	62 (30.5)	25.685	^b<0.001
moderate	11 (28.2 )	110 (54.2 )
Serious	20 (51.3 )	31 (15.3)
Participation in prenatal education(%)	1 (2.6)	5 (2.5)	0.001	^b0.970
husband-wife relationship(%)	18 (46.2)	87 (42.9)	0.145	^b0.704
usual	21 (53.8 )	116 (57.1)
Favourable
Relationship with one's husband's family
excellent	2 (5.1)	51 (25.1)	19.425	^b<0.001
rather or relatively good	25 (64.1)	136 (67.0)
not very good	12 (30.8)	16 (7.9)
Residence during the puerperium period(%)
Living with one's spouse	9 (23.1)	45 (22.2)	0.169	^b0.919
Living with one's parents	5 (12.8)	22 (10.8)
Living with one's in-laws	25 (64.1)	136 (67.0)
expectations are met(%)	23 (59.0)	135 (66.5)	0.818	^b0.366
breastfeeding(%)
mother's milk	15 (38.5)	169 (83.3)	36.015	^b<0.001
infant formula	24 (61.5 )	34 (16.7)
Prolonged childbirth(%)	0	2 (1.0)	0.706	^b0.401
unwanted pregnancy(%)	2 (5.1)	6 (3.0)	0.042	^b0.837
Regular maternity check-ups(%)	37 (94.9)	199 (98.0)	1.349	^b0.245
postpartum haemorrhage(%)	2 (5.1)	1 (0.5)		^b0.068
Satisfaction with medical staff(%)	34 (87.2)	188 (92.6)	0.657	^b0.418
Data are presented as the mean ± standard deviation or n (%).
b: Pearson's chi-squared test

(3) Pain in both groups

We statistically analyzed the NRS scores after delivery as shown in the table below. The pain in both the depressed and nondepressed groups gradually decreased with time. When the two groups were compared, the NRS scores of the depressed group were significantly greater than those of the nondepressed group at 24 hours after delivery, 3 days after delivery, and 3 months after delivery (P > 0.05) (Table 3).

Table 3

*Comparison of NRS scores at different times between the two groups*
NRS	24 hours after delivery	3 days after delivery	3 months after delivery
depresssed group	5.0 (4.0,8.0)	3.0 (0,4.0)	0 (0,1.0)
Nondepressed group	5.0 (3.0,8.0)	2.0 (0,3.0)	0
Z	-1.456	-0.931	-1.094
P	^c0.145	^c0.352	^c0.274
The data are presented as the mean ± standard deviation (n%) or median (P₂₅, P₇₅).
c: Mann–Whitney U test

(4) Newborn-related situations

The neonates’ data were statistically analyzed, and the results are shown in the table. The weight of the newborns in the depressed group was 3351.54 ± 589.56 g, and that of the newborns in the nondepressed group was 3399.90 ± 435.0 g; the difference was not statistically significant (P > 0.05). There was no significant difference in neonatal sex between the depressed group and the nondepressed group (P > 0.05). For neonatal regression, the difference between the two groups was statistically significant (P < 0.05), i.e., neonatal regression had an effect on maternal depression. There was no significant difference in the 1-minute or 5-minute Apgar score between the depressed group and nondepressed group (P > 0.05) (Table 4).

Table 4 *Neonates in the two groups*
norm	depressed group	Nondepressed group	Z	P
SAS(%)
normal	0	149 (73.4)	116.207	^c<0.001
mild anxiety	11 (28.2)	45 (22.2)
moderate anxiety	20 (51.3)	9 (4.4)
high anxiety	8 (20.5)	0
SDS(%)
normal	12 (30.8)	195 (96.1)	112.727	^c<0.001
mild depression	27 (69.2)	8 (3.9)
The data are presented as the mean ± standard deviation (n%) or median (P₂₅, P₇₅).
c: Mann–Whitney U test

5.Comparison of SAS and SDS scores between the two groups

We statistically analyzed the SAS and SDS scores between the two groups, and the results are shown in the table below. The overall anxiety level of the depressed group was significantly greater than that of the nondepressed group (P < 0.05). The SDS scores in the depressed group was significantly greater than those in the nondepressed group (P < 0.05) (Table 5).

Table 5

*Comparison of SAS and SDS scores between the two groups*
norm	depressed group	Nondepressed group	Z	P
SAS(%)
normal	0	149 (73.4)	116.207	^c<0.001
mild anxiety	11 (28.2)	45 (22.2)
moderate anxiety	20 (51.3)	9 (4.4)
high anxiety	8 (20.5)	0
SDS(%)
normal	12 (30.8)	195 (96.1)	112.727	^c<0.001
mild depression	27 (69.2)	8 (3.9)
The data are presented as the mean ± standard deviation (n%) or median (P₂₅, P₇₅).
c: Mann–Whitney U test

(6) Multifactorial analysis of factors affecting PPD occurrence

We included the indicators that had statistically significant differences in the univariate analysis, such as age, the number of deliveries, the use of pain medication, comorbid during pregnancy, neonatal regression, and adverse maternal history, in the multifactorial logistic regression, as shown in the table below. Advanced maternal age was a risk factor for maternal depression, and the greater the age was, the greater the risk of maternal depression (OR = 1.31, p < 0.05). A second birth was a protective factor against maternal depression (OR = 0.09, P < 0.05). The SAS score was a risk factor for maternal depression; the higher the level of maternal anxiety was, the greater the risk of depression (OR = 8.48, P < 0.05). A high SDS score was a risk factor for maternal depression, and mild depression was a risk factor for maternal PPD (OR = 10.99, P < 0.05) (Table 6).

Table 6

*Multifactorial analysis of factors affecting PPD occurrence*
Considerations	B	S.E.	Wad	p	OR	95% CI
Considerations	B	S.E.	Wad	p	OR	lower limit	limit
Age	0.27	0.12	5.28	0.02	1.31	1.04	1.66
Time of birth (seconds)	-2.45	0.96	6.51	0.01	0.09	0.01	0.57
Use of pain medication	0.25	0.83	0.09	0.77	1.28	0.25	6.54
Comorbidities during pregnancy	-0.47	0.85	0.30	0.58	0.63	0.12	3.33
Neonatal transfer (NICU)	0.21	1.02	0.04	0.84	1.23	0.17	9.17
Adverse maternal history	1.25	1.07	1.37	0.24	3.50	0.43	28.43
Sleep quality during pregnancy	0.21	0.50	0.18	0.67	1.24	0.47	3.27
Labor pain level	0.74	0.57	1.71	0.19	2.10	0.69	6.40
Relationship with one’s husband's family			1.91	0.39
Relationship with one’s husband's family (1)	1.96	1.93	1.04	0.31	7.12	0.16	312.19
Relationship with one’s husband's family (2)	2.78	2.10	1.75	0.19	16.04	0.26	978.54
Formula feeding	1.27	0.83	2.33	0.13	3.56	0.70	18.16
SAS score	2.14	0.58	13.71	< 0.001	8.48	2.73	26.27
SDS score	2.40	0.83	8.44	< 0.001	10.99	2.18	55.37
S. E: standard error
OR: Odds ratio
CI: confidence interval

PPD is a recognized public health problem that refers to the development of depressive symptoms after childbirth and is a common type of puerperal psychiatric syndrome. The main manifestations are depressed mood, pessimistic feelings, inexplicable crying, self-blame, low self-esteem, suicide or infanticide, and in some cases, sleep disturbances, loss of appetite and loss of energy^[13]. Several studies have shown that PPD has a significant impact on mothers' mental health and quality of life^{[14, 15]}.

The results of the present study showed that the prevalence of maternal PPD was approximately 16.1%, which is in line with the findings of Ding et al. regarding the prevalence of PPD in Chinese women^[16]. The incidence of PPD in women who underwent vaginal delivery and had intrathecal labor analgesia was 5%, the incidence of PPD in women who underwent cesarean section was approximately 11.1%, and the number of women who developed PPD after cesarean section was significantly greater than that of women who underwent vaginal delivery and had intrathecal labor analgesia. Studies have shown that different modes of delivery have significant effects on the occurrence of PPD, and the women who gave birth by cesarean section in this study had a greater risk of PPD^[17], which is consistent with the findings of Boyce et al.^[18] A higher risk of PPD was also found in our study for women who underwent cesarean section. The possible reasons for this are as follows: 1. Cesarean section is a traumatic and negative birth experience for women, and when combined with other conditions, such as underlying pregnancy disorders, it affects the maternal psychological state, increasing the risk of depression^{[19, 20]}. However, other studies have not established that a link between cesarean section and PPD^[21]. 2. Cesarean section is a stressor, incisional pain and postoperative complications affect maternal mood, and persistent pain is more common after cesarean section than after vaginal delivery^[22]. Acute pain after cesarean section increases the risk of PPD^[23], whereas effective pain control can reduce the risk of PPD^[24]. 3. Intrathecal labor analgesia can effectively relieve severe pain during labor. In a study by Lim et al., 201 women in labor were analyzed, and the greater the improvement in pain was, the lower the EPDS score was^[25]. Intrathecal labor analgesia has also been shown to improve maternal anxiety and depression levels^[26]. A meta-analysis showed that women who underwent cesarean section had a greater risk of PPD than did those who delivered vaginally and that intrathecal labor analgesia reduced the incidence of PPD^[27]. Women who received epidural labor analgesia had a lower risk of PPD than women who did not receive epidural labor analgesia^[16]. However, it has also been reported that labor epidural analgesia is not associated with a reduction in PPD risk^[28]; however, this finding is less consistent with our study.

In addition, the results of the present study revealed no statistically significant differences in maternal depression between women who underwent vaginal delivery and those who underwent cesarean section and had intrathecal labor analgesia in terms of the duration of pregnancy, weight gain during pregnancy, weight before pregnancy, BMI, education level, work status, residential status, family finances, surgical history, whether the pregnancy was planned, whether artificial insemination was used, marital relationship status, whether expectations were met, and whether prenatal education classes were received (P > 0.05). The univariate analysis revealed that advanced maternal age, number of deliveries, use of pain medication, pregnancy with underlying disease, neonatal sleep regression, poor maternal history, sleep quality during pregnancy, labor pain score, relationship with one’s husband's family, formula feeding, SAS score, SDS score, etc., may be relevant factors influencing the occurrence of PPD in women who deliver vaginally or by cesarean section with intrathecal labor analgesia. After further multifactorial analysis, advanced maternal age and SAS and SDS scores were found to be independent risk factors influencing the occurrence of PPD in women who delivered vaginally or by cesarean section with intrathecal labor analgesia (P < 0.05).

Several studies have shown that there is a strong link between maternal age and PPD incidence and that advanced maternal age can increase the likelihood of PPD^[29]. The results of the present study also suggested that older mothers had a greater incidence of PPD, which may be associated with maternal and fetal complications during pregnancy^[30]. Regarding the influence of the number of births on PPD incidence, it may be that women who have previously given birth tend to have less anxiety and stress about labor than first-time mothers^[31]. Underlying comorbid conditions during pregnancy are also associated with the development of PPD, and the risk of PPD increases with perinatal complications; for example, mothers with preeclampsia have elevated levels of serotonin in the blood, while serotonin levels in the brain are reduced, which may lead to depression^{[19, 32, 33]}.

The SDS score is used to assess maternal antenatal depression, which is the greatest risk factor for PPD^{[34, 35]}. The SAS score reflects maternal anxiety during the antenatal period, and our study suggested that antenatal depression and antenatal anxiety are factors affecting PPD risk and that some women who are afraid of pain during labor and worry about their babies are prone to excessive anxiety. Mothers with high anxiety during pregnancy are three times more likely to have PPD than women without high anxiety during pregnancy^[36]. Several relevant studies have confirmed that prenatal anxiety and prenatal depression are risk factors for PPD in Chinese women^[37].

In our study, maternal sleep deprivation during pregnancy was also an influential factor of maternal PPD due to changes in the body, uterine compression of the bladder, frequent nocturia, frequent awakenings at night, and interrupted sleep. One prospective study analyzed maternal sleep before pregnancy and at 12, 24 and 36 weeks of pregnancy and revealed that sleep deprivation at 36 weeks of pregnancy was significantly associated with PPD^[38]. Neonatal regression, adverse maternal history, labor pain scores, and the relationship with one’s husband's family were factors associated with PPD.

In conclusion, our findings suggest that advanced maternal age, prenatal anxiety and prenatal depression are associated with the development of PPD in women who undergo vaginal delivery and receive intrathecal labor analgesia and those who undergo cesarean section. Obstetricians and gynecologists should identify mothers at high risk of PPD early and provide enhanced psychological counseling to mothers to reduce the incidence of PPD. However, studies with large sample sizes are still needed.

All participants in our study were from one region of China, which does not provide a comprehensive picture of the total population. Additionally, we did not differentiate between elective and emergency cesarean sections, and there is literature showing that^[27] emergency cesarean section is associated with a greater risk of PPD than is elective cesarean section. Finally, our sample size was limited, and further large-sample studies are needed.

PPD: Postpartum Depression

CS: Cesarean Section

EmCS: Emergency Cesarean Section

SAS: Self-Rating Anxiety Scale

SDS: Self-Rating Depression Scale

EPDS: Edinburgh Postnatal Depression Scale

Funding statement

This research was funded by a grant from the 2021 Clinical Medicine Discipline Construction Project of Anhui Medical University (project number 2021lcxk040). The funding source was not involved in the study design; the collection, analysis or interpretation of the data; the writing of the report; or the decision to submit the report for publication.

Conflict of interest statement

The authors declare that they have no competing interests.

Data availability statement

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

Transparency statement

Xiaoqiong Xia affirms that this manuscript is an honest, accurate, and transparent account of the study being reported, that no important aspects of the study have been omitted, and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

All the authors have read and approved the final version of the manuscript.

The full trial protocol is available from the corresponding author upon reasonable request.

Authors’ contributions

Xiaomei Xu: Conceptualization; writing – review and editing. Ming Yang: Writing – original draft. Haoyu Ji: Writing – original draft. Pengfei Gao: Data curation. Cheng Qiu: Data curation. Xiaoqiong Xia: Conceptualization; writing – review and editing. Yuanhai Li: Methodology.

ACKNOWLEDGMENTS

I would like to sincerely thank Lixia Cheng and Cheng Qiu for their advice, and I would like to thank my anaesthesia colleagues at Chaohu Hospital of Anhui Medical University for their help in guiding my trial, because it was only with them that I could make it go more smoothly, and more importantly, I would like to thank my patients for making the trial I planned possible. This study was funded by the Clinical Medicine Discipline Construction Project of Anhui Medical University in 2021, project number 2021lcxk040, and the funding source was not involved in the decision of experimental design, data design, analysis and interpretation, report writing, or report publication.

ETHICS STATEMENT

The study was approved by the Ethics Committee of Chaohu Hospital ,Anhui Medical University and the ethical approval number is KYXM-202312-004

Consent to Publish

The author confirms:

that the work described has not been published before (except in the form of an abstract or as part of a published lecture, review, or thesis);

that it is not under consideration for publication elsewhere;

that its publication has been approved by all co-authors, if any;

that its publication has been approved (tacitly or explicitly) by the responsible authorities at the institution where the work carried out.

Brummelte S, Galea L A. Depression during pregnancy and postpartum: contribution of stress and ovarian hormones [J]. Prog Neuropsychopharmacol Biol Psychiatry, 2010, 34(5): 766-76.
Katon W, Russo J, Gavin A. Predictors of Postpartum Depression [J]. Journal of Women's Health, 2014, 23(9): 753-9.
Abdollahi F, Sazlina S G, Zain A M, Zarghami M, Asghari Jafarabadi M, Lye M S. Postpartum depression and psycho-socio-demographic predictors [J]. Asia Pac Psychiatry, 2014, 6(4): 425-34.
Friedman S H, Resnick P J. Postpartum depression: an update [J]. Womens Health (Lond), 2009, 5(3): 287-95.
Groer M W, Morgan K. Immune, health and endocrine characteristics of depressed postpartum mothers [J]. Psychoneuroendocrinology, 2007, 32(2): 133-9.
Figueiredo B, Pacheco A, Costa R, Conde A, Teixeira C. Mother's anxiety and depression during the third pregnancy trimester and neonate's mother versus stranger's face/voice visual preference [J]. Early Hum Dev, 2010, 86(8): 479-85.
Herrera E, Reissland N, Shepherd J. Maternal touch and maternal child-directed speech: effects of depressed mood in the postnatal period [J]. J Affect Disord, 2004, 81(1): 29-39.
Goodman S H, Rouse M H, Connell A M, Broth M R, Hall C M, Heyward D. Maternal depression and child psychopathology: a meta-analytic review [J]. Clin Child Fam Psychol Rev, 2011, 14(1): 1-27.
O'Hara M W, McCabe J E. Postpartum Depression: Current Status and Future Directions [J]. Annual Review of Clinical Psychology, 2013, 9(1): 379-407.
Guo L Ma A. A survey on the prevalence of postpartum depression and its influencing factors [J]. China Medical Journal, 2007, (32): 28-31.
Wong C A. Advances in labor analgesia [J]. Int J Womens Health, 2010, 1: 139-54.
Cox J L, Holden J M, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale [J]. Br J Psychiatry, 1987, 150: 782-6.
PAN Yingming, XU Jihong, YAN Panpan, LIU Xiaoyu. Current status of research on the effects of postpartum depression on mothers and offspring [J]. China Family Planning and Obstetrics and Gynaecology, 2022, 14(12): 7-10.
Slomian J, Honvo G, Emonts P, Reginster J Y, Bruyere O. Consequences of maternal postpartum depression: A systematic review of maternal and infant outcomes [J]. Womens Health (Lond), 2019, 15: 1745506519844044.
Field T. Postpartum depression effects on early interactions, parenting, and safety practices: a review [J]. Infant Behav Dev, 2010, 33(1): 1-6.
Ding T, Wang D X, Qu Y, Chen Q, Zhu S N. Epidural labor analgesia is associated with a decreased risk of postpartum depression: a prospective cohort study [J]. Anesth Analg, 2014, 119(2): 383-92.
Sun L, Wang S, Li X Q. Association between mode of delivery and postpartum depression: A systematic review and network meta-analysis [J]. Aust N Z J Psychiatry, 2021, 55(6): 588-601.
Boyce P M, Todd A L. Increased risk of postnatal depression after emergency caesarean section [J]. Med J Aust, 1992, 157(3): 172-4.
Blom E A, Jansen P W, Verhulst F C, et al. Perinatal complications increase the risk of postpartum depression. The Generation R Study [J]. BJOG, 2010, 117(11): 1390-8.
Eckerdal P, Georgakis M K, Kollia N, Wikstrom A K, Hogberg U, Skalkidou A. Delineating the association between mode of delivery and postpartum depression symptoms: a longitudinal study [J]. Acta Obstet Gynecol Scand, 2018, 97(3): 301-11.
Carter F A, Frampton C M, Mulder R T. Cesarean section and postpartum depression: a review of the evidence examining the link [J]. Psychosom Med, 2006, 68(2): 321-30.
Kainu J P, Halmesmaki E, Korttila K T, Sarvela P J. Persistent Pain After Cesarean Delivery and Vaginal Delivery: A Prospective Cohort Study [J]. Anesth Analg, 2016, 123(6): 1535-45.
Shen D, Hasegawa-Moriyama M, Ishida K, Fuseya S, Tanaka S, Kawamata M. Acute postoperative pain is correlated with the early onset of postpartum depression after cesarean section: a retrospective cohort study [J]. J Anesth, 2020, 34(4): 607-12.
Wisner K L, Stika C S, Clark C T. Double Duty [J]. Anesthesia & Analgesia, 2014, 119(2): 219-21.
Lim G, Farrell L M, Facco F L, Gold M S, Wasan A D. Labor Analgesia as a Predictor for Reduced Postpartum Depression Scores: A Retrospective Observational Study [J]. Anesth Analg, 2018, 126(5): 1598-605.
BAI Yunbo, XU Mingjun, CHE Xiangming. Exploring the effect of analgesia in labour [J]. International Journal of Anaesthesiology and Resuscitation, 2019, (01): 76-80.
Xu H, Ding Y, Ma Y, Xin X, Zhang D. Cesarean section and risk of postpartum depression: A meta-analysis [J]. J Psychosom Res, 2017, 97: 118-26.
Kountanis J A, Vahabzadeh C, Bauer S, et al. Labor epidural analgesia and the risk of postpartum depression: A meta-analysis of observational studies [J]. J Clin Anesth, 2020, 61: 109658.
Youn H, Lee S, Han S W, et al. Obstetric risk factors for depression during the postpartum period in South Korea: a nationwide study [J]. J Psychosom Res, 2017, 102: 15-20.
Usta I M, Nassar A H. Advanced maternal age. Part I: obstetric complications [J]. Am J Perinatol, 2008, 25(8): 521-34.
Tamaki R, Murata M, Okano T. Risk factors for postpartum depression in Japan [J]. Psychiatry Clin Neurosci, 1997, 51(3): 93-8.
Bolte A C, van Geijn H P, Dekker G A. Pathophysiology of preeclampsia and the role of serotonin [J]. Eur J Obstet Gynecol Reprod Biol, 2001, 95(1): 12-21.
Bloch M, Schmidt P J, Danaceau M, Murphy J, Nieman L, Rubinow D R. Effects of gonadal steroids in women with a history of postpartum depression [J]. Am J Psychiatry, 2000, 157(6): 924-30.
Leigh B, Milgrom J. Risk factors for antenatal depression, postnatal depression and parenting stress [J]. BMC Psychiatry, 2008, 8: 24.
Heron J, O'Connor T G, Evans J, Golding J, Glover V, Team A S. The course of anxiety and depression through pregnancy and the postpartum in a community sample [J]. J Affect Disord, 2004, 80(1): 65-73.
Kaydirak M, Yilmaz B, Demir A, Oskay U. The relationships between prenatal attachment, maternal anxiety, and postpartum depression: A longitudinal study [J]. Perspect Psychiatr Care, 2022, 58(2): 715-23.
Qi W, Zhao F, Liu Y, Li Q, Hu J. Psychosocial risk factors for postpartum depression in Chinese women: a meta-analysis [J]. BMC Pregnancy Childbirth, 2021, 21(1): 174.
Yun B S, Shim S H, Cho H Y, et al. The impacts of insufficient sleep and its change during pregnancy on postpartum depression: A prospective cohort study of Korean women [J]. Int J Gynaecol Obstet, 2021, 155(1): 125-31.

No competing interests reported.

Analysis of Intrathecal Labor Analgesia and the Causes of Maternal Postpartum Depression After Cesarean Section

Status:

Version 1

Abstract

Figures

1. Introduction

2. METHODS

2.1 Research design and ethics

2.2 Recruitment of participants

2.3 Data collection

2.4 Data analysis

3. RESULTS

3.1 Maternal PPD status

3.2 Unifactorial analyses affecting PPD occurrence

4. Discussion

5. Limitations

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1