Vol. 13 Issue 6
The Forgotten Component of Postpartum Assessment
A Strategy for Determining Postpartum Fatigue
Fatigue has not been adequately addressed in the postpartum population and has a significant impact on the health, functioning and parenting ability of the new mother.1 In addition to negatively affecting the woman herself, postpartum fatigue may also have a profound impact on her newborn as well as other members of the family unit.
The postpartum period, also referred to as the puerperium or fourth trimester, consists of physiologic and psychological changes the new mother must adapt to in response to pregnancy and childbirth. During this time of adaptation, the woman is also required to assume the many responsibilities of a mother, which include the care and nurturing of the newborn infant. These adaptive responses and responsibilities typical of the postpartum period require significant physical, psychological and emotional energy. An even greater amount of energy may be required of the woman who has experienced an antepartum, intrapartum or postpartum complication.
This article raises awareness about the need to incorporate fatigue assessment as a routine, necessary component of postpartum care and offers a strategy for doing so.
Inpatient Postpartum Care
The routine inpatient nursing care of the postpartum woman has traditionally focused on physical assessment activities along with specific nursing interventions related to physiologic response to pregnancy and childbirth. Standards set by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) require nurses to incorporate assessment, management and reassessment of pain into the nursing plan of care.2 Nursing assessment of fatigue and patterns of sleep and rest, including the use of a standard fatigue assessment tool, is not a routine component of inpatient postpartum nursing care, however.
Follow-Up Postpartum Care
Follow-up postpartum examinations typically occur between 2 and 6 weeks after discharge from the hospital. These exams, performed by NPs or physicians, typically focus on physiologic return to the prepregnant state. They may include an evaluation of adaptation to the role of mother but do not routinely include an assessment of sleep and rest patterns or an assessment of fatigue using a standard assessment tool. Most women do not routinely return for another visit with their obstetric or gynecologic care provider until their annual gynecologic examination a year after this postpartum visit.
Factors Influencing Postpartum Fatigue
There is a common and inaccurate assumption that the period of hospitalization immediately following childbirth is a time of recovery and rest.3 Yet many factors preclude adequate rest during this time. The shortening of the average hospital stay to 48 hours or less (for vaginal delivery) can influence postpartum fatigue. New mothers have less time for rest and receiving breastfeeding and infant care assistance. Shortened hospital stays have made it difficult for nurses to assess and assist in managing postpartum fatigue.4 In some cases, reports of postpartum fatigue are overlooked or considered normal.5
Postpartum units have undergone changes in physical design that may increase fatigue in postpartum women. In the past, a typical postpartum unit included a hospital room for the new mother and a newborn nursery area for the newborn infant, with a nurse assigned to provide care for each. The newborn babies were taken to the nursery at night and as requested by the mother to allow the mother time for rest and sleep. Routine visiting hours were often limited, which also provided mothers with periods of sleep and rest. With the advent of rooming-in maternity care to provide for a more home-like atmosphere, mothers and their newborns are encouraged to remain together following birth to promote maternal-infant bonding and skills. Visiting hours are often more liberal in this home-like environment, with some units allowing 24-hour-a-day visitation. Although positive effects of the rooming-in model have been documented, its effects on maternal fatigue need further research.
Current nursing staffing patterns on combined maternal-newborn units also contribute to maternal fatigue. These patterns are based on the assumption that individual nurses will be assigned to care for a specific number of mother-infant couplets based on patient acuity. At times, nurses may not be available to care for the newborns whose mothers choose to rest and sleep.
The role of women in our society has changed over time, also contributing to their increasing levels of fatigue during pregnancy and following childbirth. Millions of women remain in the work force during pregnancy, and more than half of new mothers in the United States return to work after the birth of a child.5 Many women do not have extended family support systems in their immediate geographical area to assist with family and household responsibilities.
Due to these as well as other factors, women are potentially more fatigued during pregnancy and may also experience increased levels of fatigue during the hospital stay and after they return home.
Defining and Measuring Fatigue
Although fatigue is one of the most common concerns cited by patients, it is difficult to conceptually define. There are there many types of fatigue and many subjective responses to fatigue. Published definitions of fatigue include that from the North American Nursing Diagnosis Association (NANDA): "the self-recognized state in which an individual experiences an overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work that is not relieved by rest."6 The Center for Biobehavioral Studies of Fatigue Management at the University of Kansas School of Nursing systematically studies fatigue in diverse populations.7 The center defines fatigue as "the awareness of a decreased capacity for physical and mental activity due to an imbalance in the availability, utilization or restoration of resources needed to perform activity."7 The premise is that fatigue occurs when there are insufficient resources because the demand or need is too great or because mechanisms of utilization and restoration are disturbed.7
Several researchers have developed assessment tools for postpartum fatigue.8-11 Despite these publications, there are no widely accepted clinical instruments to measure maternal fatigue.12 Efforts continue on this front, however. Tools used in actual practice include two modifications of Yoshitake's Fatigue Symptom Checklist (FSC), a 30-item self-report adjective checklist consisting of three 10-item subscales.13 These modified fatigue measurement tools are the Fatigue Identification Form, which consists of 30 items requiring a dichotomous yes-or-no response, and the Fatigue Continuum Form, consisting of 30 items requiring an ordinal response.14,15 The Postpartum Fatigue Assessment Form, a 30-item instrument designed to screen women at risk for developing fatigue-related problems during the immediate postpartum period, has also been published.5 In addition, an 18-item fatigue subscale of the Visual Analog Scale (VAS-F) has been used to examine the natural evolution of fatigue levels.16,17
Although attempts have been made to define and measure postpartum fatigue, a clinically useful, easy-to-use fatigue measurement tool is not available. We developed the Postpartum Fatigue Visual Analog Scale (PFVAS; Table 1) to meet this need.
To more effectively recognize and address postpartum fatigue, we recommend that all postpartum units implement the Postpartum Fatigue Awareness Program we developed in conjunction with the PFVAS (Table 2). Our proposed program includes use of the PFVAS as well as related nursing interventions to decrease fatigue and increase staff and patient awareness about this problem.
The PFVAS, a 10-point horizontal visual analog scale, allows the postpartum woman to subjectively rate her fatigue on a scale of 0 (no fatigue) to 10 (extreme fatigue). The PFVAS should be a permanent component of postpartum assessment. Upon admission to a postpartum unit following completion of immediate post-delivery care, a nurse should provide appropriate information to the new mother, along with her support person, about the concept of postpartum fatigue and explain the purpose and use of the PFVAS. The nurse should perform an initial assessment of fatigue at this time. Continued fatigue assessment should be incorporated into the routine assessment schedule established by individual unit guidelines. The nurse should also utilize the PFVAS on an ongoing basis when the evaluation of subjective or objective data indicates maternal fatigue.
The inclusion of the PFVAS as a standard component of postpartum nursing care is the first step in the development of a comprehensive Postpartum Fatigue Awareness Program. Unit protocols need to be developed to indicate specific nursing interventions that can be used based on levels of fatigue indicated by PFVAS results. For example, if a woman rates her fatigue as "4" or greater on the PFVAS right after childbirth, the nurse might offer to care for the newborn in the nursery to allow the woman time for rest and sleep. Additional nursing interventions designed to decrease fatigue during the in-hospital postpartum period should include the general reduction of noise and activity levels on the postpartum unit, coordination of patient care activities to provide for periods of uninterrupted rest and sleep, and the assignment of single postpartum rooms when available.
The comprehensive Postpartum Fatigue Awareness Program should involve members of the nursing staff as well as department physicians and ancillary staff members. This contributes to continuity of care, and training is required to foster understanding and appropriate actions by the entire team. Ongoing evaluation of the Postpartum Fatigue Awareness Program, including use of the PFVAS, should be performed to identify areas that are successful or need improvement.
In addition to educational materials for staff training, patients require their own educational materials for reference in the hospital and at home. This allows fatigue assessment to continue at the follow-up exam 2 to 6 weeks postpartum.
Clinical Use by NPs
We recommend that the PFVAS become a permanent component of the postpartum assessment tools used by NPs at postpartum follow-up visits and that the assessment of fatigue become a standard of care. Based on levels of fatigue indicated on the PFVAS, NPs can assist postpartum women in identifying specific interventions designed to decrease fatigue. Table 3 lists practical interventions that NPs can recommend.
Other recommended interventions might include seeking assistance for care of other children as well as assistance with household tasks such as laundry and cooking. Follow-up visits or phone contact can be scheduled as indicated to reassess fatigue and evaluate the effectiveness of specific interventions.
More Research Needed
Postpartum fatigue is common. Continued research will further enlighten health care providers about this issue. In the meantime, women's health nurse practitioners and nurses in postpartum units can begin to address this problem by incorporating the Postpartum Fatigue Awareness Program and PFVAS and continuing to develop and implement specific interventions to decrease fatigue in this population. Our hope is that fatigue will no longer be the forgotten component of postpartum assessment.
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Johnett Benson-Soros is a master's-prepared women's health nurse practitioner who is an assistant professor at Kent State University's Ashtabula, Ohio, campus. Greer Glazer is a women's health nurse practitioner with a PhD who is dean of the College of Nursing and Health Sciences at the University of Massachusetts in Boston.