Network analysis and trajectories of maternal emotional symptoms during labor | BMC Psychology

We conducted a study on Chinese women giving birth vaginally, examining emotional changes during childbirth. Panic, depression, fatigue, and nervousness were identified as core symptoms. Each stage of childbirth had distinct core symptom groups, showing strong associations between symptoms. The study revealed similar network patterns across the three stages, providing theoretical evidence for maternal emotion characteristics and targeted interventions.

According to network analysis theory, in this study’s network structure, there is a strong link between depression and tension, aligning partially with previous research [24]. Nervousness and depression are recognized as concurrent symptoms closely related in pathophysiology [25]. Nervousness intensifies the body’s mental and physical response to external stimuli. During labor, stress can trigger various physiological reactions, such as increased activity in the sympathetic-adrenal medulla and hypothalamic-pituitary-adrenal cortex systems [26]. Excessive nervousness or depression reduces norepinephrine secretion and causes hormonal changes, leading to muscle tension, fatigue, delayed labor, and dystocia [27, 28]. Additionally, it poses risks to fetal intelligence and newborns’ lives [27, 29]. Studies indicate a weak positive correlation between fear of childbirth and anxiety sensitivity with somatosensory symptoms [30]. Additionally, the link between anxiety and depression, as well as tension, is somewhat inconsistent with previous results. Anxiety occurs when the brain receives external stimuli, prompting it to send commands to initiate the neuroendocrine system and the sympathetic nervous system [31]. When the sympathetic nervous system becomes more active, it is often accompanied by increased secretion of adrenal medulla, leading to the release of adrenaline and noradrenaline, which enhances the excitatory effects of the sympathetic nervous system [32]. This resulted in elevated blood pressure, increased heart rate, and dilated pupils, manifesting as heightened excitement and tension.

Given the cross-sectional nature of this study, it is evident that anxiety, depression, and tension consistently represent core symptom features, even though bridge symptoms did not appear in the network structure. Intervening in comorbid scenarios of psychological stress reactions is a priority to block or reduce mutual transmission of different symptoms, crucial for attenuating psychological stress reactions. Network analysis studies highlight the importance of intervening in psychological distress and enhancing emotional well-being as high-impact targets throughout the disease trajectory [33]. Targeted interventions for emotional symptoms, particularly social and psychological support, may effectively reduce the overall burden of emotional symptoms [34]. Priority consideration should be given to interventions for maternal emotions, with early implementation upon identification of specific emotions in postpartum women. Developing interventions targeting feelings of anxiety, depression, and tension is crucial for alleviating the overall symptom burden for postpartum women. The childbirth experience may increase conflict between a woman’s self-worth and the external environment, leading to increased sensitivity, cognitive biases, and negative emotions, ultimately impacting the perception of stress during childbirth [35]. Additionally, research suggests that depression and anxiety may impact labor pain, highlighting the growing importance of understanding the two-way interaction between pain and emotional health, particularly in obstetrics [36, 37]. The existing literature on anxiety and pain after surgery in non-obstetric surgical subspecialties suggests that there may be a relationship between pain and anxiety [38].

Curzik and Jokic-Begic [39] also studied dimensions of anxiety sensitivity related to perinatal pain. Physical concern about the anxiety dimension was related to fear of the physical symptoms of anxiety because patients perceived symptoms of anxiety as symptoms of physical illness. Physical worry about the anxiety dimension contributes to anxiety sensitivity during childbirth. Physical worry in the anxiety dimension was related to the greatest pain during childbirth (r = 0.292, P < 0.05). This revealed that fear of physical symptoms of anxiety may also influence labor pain because it gave rise to women’s fear of childbirth. Anxiety sensitivity was thought to promote fear responses when mothers were highly stressed during delivery. This may exacerbate concerns about physiological responses during labor, increase fear of labor, and ultimately increase physiological responses and sensory labor pain.

In this study’s network structure, fatigue was prominent in the first and second stages but weaker in the third, aligning with labor progression. Women experience increasing and persistent fatigue as they enter the active stage, resulting in decreased physical and mental capacity. Fatigue peaks when the cervix fully dilates and diminishes towards the end of labor. The study also found a strong independent correlation between self-esteem and energy, positive emotions, with weak negative correlations to other symptoms, suggesting a mutual inhibitory effect between positive and negative emotions. Prioritizing interventions targeting negative emotions, considering their dominance during childbirth, may benefit outcomes. Moreover, the perception of stressors varies by the individual, and postpartum women experience stress responses. Stress is a natural response to adverse situations that disrupt homeostasis, causing physical and emotional changes and varying degrees of adaptation. Midwives should recognize postpartum women’s individual social factors, including life experiences, personalities, and needs, and provide individualized care, emphasizing psychosocial factors and providing mental health education for the benefit of postpartum women.

Limitation

This study is a single-center sampling study with a small sample size, which may impact the stability of the network. Additionally, this is a cross-sectional study, limiting the determination of causal relationships between symptoms. We also only focused on women from one specific cultural background, further research exploring maternal emotions from different cultural contexts is warranted. Another limitation lies in the dependence on self-report measures only, all the psychiatric symptoms were evaluated and reported by the women themselves. Finally, 74% of the participants were primiparous women and 83.61% were in the labor analgesia population, which may affect the generalizability of the results. In the future, we will expand the sample size to explore changes in maternal labor emotions in populations with different characteristics.