Physiological and psychological stress responses to labor and delivery as expressed by salivary cortisol: a prospective study


      Labor is considered a stressful event, yet no study has described the course of stress measured by cortisol during labor and postpartum.


      The objective of the study was to describe the patterns of physiological and psychological stress during labor as measured by salivary cortisol concentrations and stress questionnaires and their correlation to obstetric and neonatal outcomes.

      Study Design

      This prospective, observational study included 167 women with low-risk, singleton, term deliveries at a tertiary academic center. Physiological stress was evaluated by salivary cortisol measurements and emotional stress by questionnaire (stress scale ranging from 0 to 10) during the latent phase, active phase, and full dilation stages of labor as well as 2 minutes, 2 hours, and 24 hours after delivery. Cord blood cortisol and pH were also obtained. Modes of delivery, complications during labor and delivery, and early neonatal outcomes were evaluated.


      Salivary cortisol concentrations increased gradually from latent phase to active phase. The maximum increase was observed within 2 minutes of the delivery (from an average of 1.06 μg/dL to 1.67 μg/dL; 57% increase). Within 2 hours after delivery, cortisol decreased and reached a nongravid concentration after 24 hours (0.16 μg/dL). Cortisol concentrations during labor and up to 2 hours postpartum were above the average concentration of nongravid women (0.5 μg/dL). Women with epidural anesthesia had lower cortisol concentrations at complete dilation (P = .026) and 2 hours postpartum (P = .016) compared with women without epidural. Psychological stress peaked during latent and full dilation phases (mean 4.56 and 4.29, respectively). Maximum decrease from 4.29 to 2.04 (52%) occurred immediately postpartum. Cord cortisol was higher among women delivered by vacuum extraction compared with spontaneous vaginal delivery (17 ± 2 vs 11 ± 3.8, P = .03).


      This study reveals the course of cortisol concentrations during labor for low-risk pregnancies, with maximum increase immediately postpartum. Subjective stress levels decreased over the course of labor. Salivary cortisol portrays stress during labor and may be used as a reference to evaluate complicated pregnancies and to evaluate the role of cortisol during these deliveries.

      Key words

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        • Baum A.
        Stress, intrusive imagery, and chronic distress.
        Health Psychol. 1990; 6: 653-675
        • Bozovic D.
        • Racic M.
        • Ivkovic N.
        Salivary cortisol levels as a biological marker of stress reaction.
        Med Arch. 2013; 67: 374-377
        • Spielberger C.D.
        • Gorsuch R.L.
        • Lushene R.
        Manual for the State/Trait Anxiety Inventory.
        Consulting Psychologists Press, Palo Alto (CA)1970
        • Wazen R.M.
        • Kuroda S.
        • Nishio C.
        • Sellin K.
        • Brunski J.B.
        • Nanci A.
        Cortisol as a biomarker of stress in term human labor: physiological and methodological issues.
        Biol Res Nurs. 2014; 8: 1385-1395
        • De Weerth C.
        • Buitelaar J.K.
        Cortisol awakening response in pregnant women.
        Psychoneuroendocrinology. 2005; 30: 902-907
        • Willcox D.L.
        • Yovich J.L.
        • McColm S.C.P.J.
        Progesterone, cortisol and oestradiol-17 beta in the initiation of human parturition: partitioning between free and bound hormone in plasma.
        Br J Obstet Gynaecol. 1985; 92: 65-71
        • Fernández-Campos F.J.
        • Escrivá D.
        • Palanca J.M.
        • Ridocci F.
        • Barrios C.
        • Gallego J.
        Women’s acute anxiety variations before and after epidural anesthesia for childbirth.
        J Psychosom Obstet Gynecol. 2017; 38: 152-158
        • Paul I.M.
        • Downs D.S.
        • Schaefer E.W.
        • Beiler J.S.
        • Weisman C.S.
        Postpartum anxiety and maternal-infant health outcomes.
        Pediatrics. 2013; 131: e1218-e1224
        • Umeda T.
        • Hiramatsu R.
        • Iwaoka T.
        • Shimada T.
        • Miura F .S.T.
        Use of saliva for monitoring unbound free cortisol levels in serum.
        Clin Chim Acta. 1981; 110: 2
        • Stern A.
        The Hospital Anxiety and Depression Scale.
        Occup Med (Chicago, Ill). 2014; 64: 393-394
        • Philip R.
        The Hospital Anxiety And Depression Scale.
        Heal Qual Life Outcomes. 2003; : 1-29
        • Ohnhaus E.E.
        • AR
        Methodological problems in the measurement of pain: a comparison between the verbal rating scale and the visual analogue scale.
        Pain. 1975; 1: 379-384
        • Miller N.
        • Haikin Herzberger E.
        • Pasternak Y.
        • et al.
        Does stress affect IVF outcomes? A prospective study assessing cortisol levels and stress questionnaires for women undergoing through IVF treatments.
        Reprod Biomed Online. 2019; 39: 93-101
        • Kono H.
        • Furuhashi N.
        • Shinkawa O.
        • Takahashi T.
        • Tsujiei M.
        • Yajima A.
        The maternal serum cortisol levels after onset of labor.
        Tohoku J Exp Med. 1987; 152: 133-137
        • Stjernholm Y.V.
        • Nyberg A.
        • Cardell M.
        • Höybye C.
        Circulating maternal cortisol levels during vaginal delivery and elective cesarean section.
        Arch Gynecol Obstet. 2016; 294: 267-271
        • Alehagen S.
        • Wijma B.
        • Lundberg U.
        • Wijma K.
        Fear, pain and stress hormones during childbirth.
        J Psychosom Obstet Gynecol. 2005; 26: 153-165
        • Iranmanesh A.
        • Gullapalli D.
        • Singh R.
        • Veldhuis J.
        Hypothalamo-pituitary-adrenal axis after a single epidural triamcinolone injection.
        Endocrine. 2017; 57: 308-311
      1. Downing JW, Johnson HV, Gonzalez HF, Arney TL, Herman NL Jr. The pharmacokinetics of epidural lidocaine and bupivacaine during cesarean section. Anesth Analg 84:527-32.

        • Gitau R.
        • Menson E.
        • Pickles V.
        • Fisk N.M.
        • Glover V.
        • MacLachlan L.N.
        Umbilical cortisol levels as an indicator of the fetal stress response to assisted vaginal delivery.
        Eur J Obstet Gynecol Reprod Biol. 2001; 98: 14-17
        • Weekes A.R.
        • Wade A.P.
        • West C.
        Umbilical vein cortisol after spontaneous and induced labour and at elective caesarean section.
        Br J Obstet Gynaecol. 1976; 83: 870-872
        • Mears K.
        • McAuliffe F.
        • Grimes H.
        • Morrison J.
        Fetal cortisol in relation to labour, intrapartum events and mode of delivery.
        J Obstet Gynaecol. 2004; 24: 129-132
        • Sano Y.
        • Doi T.
        • Kikuchi S.
        • Kawai K.
        • Tanaka M.
        Correlations between stress hormone levels in umbilical cord blood and duration of delivery.
        J Pak Med Assoc. 2015; 65: 782-784