Unplanned Operative Delivery is Associated with Decreased Perception of Control over Labor

Background Unplanned operative delivery is associated with postpartum depression (PPD), but the mechanism is unknown. We aimed to assess the sense of control over labor for those who had unplanned delivery (unplanned cesarean or operative vaginal delivery: uCD/OVD) versus spontaneous vaginal delivery (SVD). Methods Secondary analysis of a cross-sectional survey study of term patients admitted for delivery at a tertiary center. After delivery, patients completed the Labour Agentry Scale (LAS), a validated tool to assess perceived control over labor and birth. Demographics, obstetric and neonatal outcomes and LAS scores were compared between patients who underwent uCD/OVD versus SVD. Multivariable logistic regression to assess the relationship between uCD/OVD and LAS score controlling for confounders that differed in the bivariate analysis. Results Of the 149 patients, 50 (33.6%) underwent uCD/OVD. There were no differences in maternal age, race/ethnicity, insurance status or education level between those who had uCD/OVD versus SVD. Patients who had uCD/OVD had higher median body mass index (BMI) than those who had SVD (33.2 vs 30.1 kg/m2, p = 0.03). There were no differences in rate of medical or psychiatric morbidity between groups. Additionally, there were no differences in reason for admission, however those who had uCD/OVD had significantly longer times to delivery than those who underwent SVD (22 vs 14 hrs, p < 0.01). Gestational age at delivery was also significantly higher for those who underwent uCD/OVD compared to SVD (40.2 vs 39.6 wks, p = 0.02). For the primary outcome, LAS scores were lower for those who underwent uCD/OVD compared to SVD (146 vs. 164, p < 0.01). This remained significant even after controlling for length of labor, BMI and gestational age at delivery (p < 0.01). Conclusions Even after accounting for length of labor, uCD/OVD is associated with a reduction in perceived control over labor, which may mediate the known increased risk of PPD. Further qualitative research is needed to examine how to better support patients’ wellbeing after uCD/OVD.


Abstract Background
Unplanned operative delivery is associated with postpartum depression (PPD), but the mechanism is unknown. We aimed to assess the sense of control over labor for those who had unplanned delivery (unplanned cesarean or operative vaginal delivery: uCD/OVD) versus spontaneous vaginal delivery (SVD).

Methods
Secondary analysis of a cross-sectional survey study of term patients admitted for delivery at a tertiary center. After delivery, patients completed the Labour Agentry Scale (LAS), a validated tool to assess perceived control over labor and birth. Demographics, obstetric and neonatal outcomes and LAS scores were compared between patients who underwent uCD/OVD versus SVD. Multivariable logistic regression to assess the relationship between uCD/OVD and LAS score controlling for confounders that differed in the bivariate analysis.

Results
Of the 149 patients, 50 (33.6%) underwent uCD/OVD. There were no differences in maternal age, race/ethnicity, insurance status or education level between those who had uCD/OVD versus SVD. Patients who had uCD/OVD had higher median body mass index (BMI) than those who had SVD (33.2 vs 30.1 kg/m 2 , p = 0.03). There were no differences in rate of medical or psychiatric morbidity between groups.
Additionally, there were no differences in reason for admission, however those who had uCD/OVD had signi cantly longer times to delivery than those who underwent SVD (22 vs 14 hrs, p < 0.01). Gestational age at delivery was also signi cantly higher for those who underwent uCD/OVD compared to SVD (40.2 vs 39.6 wks, p = 0.02). For the primary outcome, LAS scores were lower for those who underwent uCD/OVD compared to SVD (146 vs. 164, p < 0.01). This remained signi cant even after controlling for length of labor, BMI and gestational age at delivery (p < 0.01).

Conclusions
Even after accounting for length of labor, uCD/OVD is associated with a reduction in perceived control over labor, which may mediate the known increased risk of PPD. Further qualitative research is needed to examine how to better support patients' wellbeing after uCD/OVD.

Background
There is increasing understanding that patient's perceived control over their labor and delivery may mitigate postpartum mental health disorders (PPMD) 1 . Compared to those who have spontaneous vaginal deliveries (SVDs), patients who undergo unplanned cesareans or operative vaginal delivery (uCD/OVD) are at increased risk of PPMD. 2 Though the difference in risk of PPMD based on delivery mode has been attributed to perceived control over childbirth, data supporting the potential association between uCD/OVD and perceived control over childbirths remains limited 3 . Using the Labour Agentry Scale (LAS)-a validated instrument that assesses patient perception of control during childbirth 4 -we aimed to examine whether patients who underwent uCD/OVD perceived less control during childbirth compared to patients who underwent SVD.

Methods
This was a preplanned secondary analysis of a cross-sectional survey study of patients admitted to the labor and delivery unit at Women & Infants Hospital of Rhode Island (WIH) from June through July 2021.
WIH is a large academic center with a catchment area that includes all of Rhode Island as well as Southern Massachusetts and Connecticut and has an annual delivery rate of approximately 8,500 deliveries. Prior to enrollment initiation, the study was approved by the institutional review board (#1691795).
Eligibility was assessed via chart review and participants were approached on the postpartum unit.
Eligible participants were nulliparous, English-speaking, and had singleton pregnancies at gestational age ≥ 37 weeks and were approached on the postpartum unit. The primary outcome was the total score for the LAS. All After obtaining consent, participants lled out a detailed survey of past medical and psychiatric history and the Labour Agentry Scale (LAS), a validated 29-item instrument that assesses childbirth control 7 . Trained medical personnel then performed a detailed chart review of their obstetric course and collected information on labor interventions, analgesia, mode of delivery, postpartum complications (hemorrhage, preeclampsia, infection) as well as neonatal outcomes including NICU admission, need neonatal treatment.
Participants who underwent uCD/OVD were compared to those who underwent SVD using Fisher's exact and Wilcoxon Rank-sum tests. Multivariable linear regression was performed to assess for confounders identi ed from the bivariate analysis.
Maternal BMI was signi cantly higher in the group which underwent uCD/OVD as compared to SVD (median 33.2 vs 30.1, respectively, p < 0.03). There were no differences between groups in terms of maternal age, race, insurance payer or maternal education (Table 1). Additionally, rates of medical comorbidities (which included chronic hypertension, gestational hypertension and preeclampsia, pregestational and gestational diabetes, thyroid disease and SARS-CoV-2 infection) and rates of depression and/or anxiety did not differ between groups (Table 2).
There were also no differences in the distribution of admission types between groups (admitted for labor, planned induction or induction admitted from triage). However, length of labor was signi cantly higher among those who underwent uCD/OVD as compared to SVD (median 22 hours vs 14 hours, p < 0.02).
Gestational age at delivery was also higher among those who underwent uCD/OVD (median 40.2 weeks) compared to SVD (median 39.6 weeks, p < 0.02). There were no differences in rates of NICU admission or the need for neonatal therapy (which included the need for supplemental oxygen, phototherapy and neonatal antibiotics).
Scores on the LAS were signi cantly lower for participants who underwent uCD/OVD (median 146) than those who underwent SVD (median 164, p < 0.01). These ndings remained signi cant after controlling for BMI, length of labor, and GA (Scores were 16.09 (± 4.64) points lower among those who underwent uCD/OVD compared to SVD, p < 0.01) ( Table 2).

Discussion
In this study, those who underwent uCD/OVD had signi cantly lower scores on the LAS than those who underwent SVD. This nding remained signi cant even after controlling for maternal BMI, gestational age at delivery and length of labor. This indicates that participants who underwent uCD/OVD experienced less control over their labor process.
These ndings are consistent with a prior study by Floris et al 3 , though their cohort was smaller -with 78 participants -and their analyses did not control for factors such as length of labor that may be associated with labor experience 3 .
Mode of delivery has been demonstrated to be a key mediator of development of PPMD, 5 impacting up to 15-20% of birthing people 6 . If the perception of losing control over childbirth mediates development of PPMD is correct, interventions to increase the experience of control must be examined. These could incorporate psychotherapeutic approaches such as cognitive behavioral therapy or education-based interventions designed to increase patient engagement in decision-making during labor. Regardless of the exact intervention, it is crucial to further explore whether improving patient perceptions of control during childbirth may decrease rates of PPMD.
Strengths of this study include that each participant had a detailed health history and labor interventions/outcomes collected from the medical chart by trained researchers. This allowed for us to compare between groups and account for differences between groups in our analysis.
For this study, we combined operative vaginal delivery and cesarean delivery as we were limited in the number of operative vaginal deliveries in our sample and both types of deliveries are high intervention births. However, there are likely differences in how these two groups experience their labor. Future studies with larger samples of operative vaginal deliveries should be performed to further assess these ndings.
A second limitation is that how LAS was only collected at a single time point during a participant's postpartum hospitalization. How a participant views their experience of childbirth may change over time. Lastly, we did not collect data on depressive symptoms so cannot correlate our ndings with rates of postpartum depression and anxiety.

Conclusion
Even after controlling for confounding factors, participant experience of control over labor was lower among those who underwent unplanned cesarean or operative vaginal delivery compared to those who underwent spontaneous vagina delivery. Increasing patient experience of control, particularly among those who have unplanned operative deliveries, may represent a target for interventions to decrease rates of postpartum mental health disorders.