Intervention Protocol

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Non-pharmacological interventions for women with postpartum fatigue

  1. Kanittha Volrathongchai1,*,
  2. Somsakhool Neelasmith1,
  3. Jadsada Thinkhamrop2

Editorial Group: Cochrane Pregnancy and Childbirth Group

Published Online: 28 MAR 2013

DOI: 10.1002/14651858.CD010444

How to Cite

Volrathongchai K, Neelasmith S, Thinkhamrop J. Non-pharmacological interventions for women with postpartum fatigue (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD010444. DOI: 10.1002/14651858.CD010444.

Author Information

  1. 1

    Khon Kaen University, Faculty of Nursing, Meung, Khon Kaen, Thailand

  2. 2

    Khon Kaen University, Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen, Thailand

*Kanittha Volrathongchai, Faculty of Nursing, Khon Kaen University, 123 Mitraphap Road, Meung, Khon Kaen, 40002, Thailand.

Publication History

  1. Publication Status: New
  2. Published Online: 28 MAR 2013




  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

Postpartum fatigue (PPF) is a common unpleasant symptom occurring in women during the first three months following childbirth, but it can persist up to 19 months after delivery (Troy 2003). Its prevalence rate is high, with estimates of approximately 50% to 54% (Ansara 2005; Glazener 1995). Affonso et al. (Affonso 1990) reported that almost 70% of the participants in their study acknowledged fatigue one to two weeks postpartum, while 40% continued to report elevated levels 12 weeks later. Postpartum fatigue precipitates physical and mental exhaustion, which may have an adverse effect on maternal physical, psychological, and social well-being. It also leads to poor maternal functional status, maternal role attainment, relationships between a mother and her baby/family, as well as decreasing the duration of breastfeeding (Pugh 1999). Furthermore, PPF is one of the crucial factors related to postpartum depression (Corwin 2005).

Given its prevalence, PPF is a concern for midwives and maternal health nurses because of the impact on the health and parenting ability of the mother. To date, there has been scant published research specifically aimed at understanding PPF, leaving a picture that is far from complete. Much of our understanding of PPF remains theoretical and untested. Currently, nursing theory provides little understanding of the factors that help to decrease fatigue or even explain how women manage fatigue.

Current treatments do exist. However, fatigue mitigation in other contexts (such as for cancer-related fatigue treatment) often consist of pharmacological interventions. Unfortunately, pharmacological interventions are not advisable for mothers who are breast feeding as the drugs used can adversely affect the newborn. For example, McNell et al (McNeil 2008), reviewed three drugs used for cancer-related fatigue treatment: methylphenidate, darbepoetin alfa, and modafinil. Methylphenidate is a psychostimulant drug using for chronic fatigue syndrome. As it can be excreted into human milk, caution is recommended if the drug is to be administered to a nursing woman. The presence of darbepoetin alfa and modafinil in breastmilk or its effects on breastfed infants has yet to be studied.

Furthermore, PPF may be caused by diverse factors, including physiological, psychological and situational conditions. Given this complexity, it may take some time to ascertain a specific cause. Because pharmacological interventions for symptom mitigation carry risks for the newborn, it is important to examine non-pharmacological alternatives.

This topic is complicated by the lack of consistency across studies regarding how PPF is defined and how outcomes are measured. Thus, we need to develop a system that will enable us to compare similar studies in the hope that we can reach significant conclusions, at least regarding broader modes of intervention. To facilitate this, such a system will need to clarify the various components of PPF by combining current knowledge regarding fatigue from other contexts and applying it to the postpartum period. As making use of such a foundation will rest squarely on how fatigue is defined, we must first examine this in more detail.

Ideally, nursing theory would be able to build upon a foundation of existing knowledge drawn from other contexts. However, current evidence-based treatments for PPF often consist of pharmacological interventions intended to address underlying causes such as anaemia, infection/inflammation, and thyroid dysfunction (Corwin 2007). Furthermore, fatigue is not only experienced physically in terms of reduced energy and activity levels, but may also affect mental or cognitive functioning, such as motivation, concentration and thinking clearly (Chee 2006; Cottrell 2002; Hockey 2000; van der Linden 2003).

While there is general agreement on what constitutes the postpartum period, in existing trials the definition of PPF remains very vaguely defined (sometimes going undefined). This is largely due to the fact that, lacking consistent objective measures and assessment tools, fatigue itself remains poorly defined and measured (Dittner 2004). Further research is needed to develop a “gold standard” to measure fatigue objectively. However, the need among women suffering from PPF is great enough that, even although there is no gold standard, the issue should be examined. To facilitate this examination, despite the challenges, in this review we intend to formulate a conceptual and operational definition for fatigue that can be used to construct a working definition of PPF that will, in turn, inform our inclusion criteria.

As outlined above, a limitation common to studies on PPF is the inconsistency of conceptualisation and measurement. Perhaps not surprisingly, given the complex interaction of the biological processes, psychosocial phenomena, and behavioural manifestations involved, defining fatigue has challenged scientists for many years. While some distinguish normal fatigue from pathological and psychological fatigue, others simply view normal fatigue as acute and pathological fatigue as chronic. From a physiological perspective, Berger et al (Berger 1991) defined fatigue as functional organ failure. Similarly, Lewis & Haller (Lewis 1991) refer to fatigue as poor physical performance resulting from the physical insufficiency imposed by fatigue. From a psychological perspective, fatigue has been defined as a state of weariness related to reduced motivation (Lee 1991).

Fatigue is a complex, multicausal, multidimensional, nonspecific, and subjective phenomenon for which no one definition is widely accepted (Tiesinga 1999). For example, Hubsky & Sears (Hubsky 1992) defined fatigue as a subjective multidimensional phenomenon with physical, behavioural, and psychological components. Milligan & Pugh (Milligan 1994) divided fatigue into four dimensions: physiologic, psychological, situational, and performance. Later, Milligan et al (Milligan 1996) conducted a concept analysis of childbearing fatigue that revealed several important characteristics of PPF, with physiological, psychological, and situational aspects that are distinct from tiredness and which can be differentiated from postpartum depression, with which there is some overlap. Furthermore, both the physical and mental aspects of PPF can be influenced by a woman’s social context.

As can be seen, definitions of "fatigue" vary widely across disciplines and applications. One attempt to standardise the definition of fatigue occurs in the Medical Subject Headings (MeSH) controlled vocabulary, where fatigue is defined as "the state of weariness following a period of exertion, mental or physical, charaterized by a decreased capacity for work and reduced efficiency to response to stimuli (National Library of Medicine 1999). In other contexts, "fatigue" has been commonly understood to be "the awareness of a decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization and/or restoration of resources needed to perform activity" (Gardner 1991).

It is beyond the scope of this review to attempt to synthesise a new approach to such a complex phenomenon. Thus, in keeping with the focus on the nursing context, for the remainder of this review, we will take our definition of fatigue from the North American Nursing Diagnosis Association (NANDA). NANDA defines fatigue as “An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level” (NANDA-I 2008).


Description of the condition

For the purposes of this review, PPF will be defined as the symptom of fatigue (as defined by NANDA-I 2008) occurring during the postpartum period. The puerperium is the period of time encompassing the first few weeks following birth; the duration of this “period” is understandably inexact, and it is considered by most to be between four and six weeks. Using the outside extreme of that range, trials to be included in this review will be those that examine fatigue experienced within the six weeks following birth.

Using these definitions, PPF will be understood to refer to the state of weariness following a period of exertion, mental or physical, characterised by a decreased capacity for work and reduced efficiency to respond to stimuli within six weeks post parturition. This corresponds well with more specific definitions in the literature.

  • Troy 2003 defined PPF as exhaustion and a diminished ability to perform mental and physiological activities that mothers experience in the postpartum period.
  • Pugh 1993 defined PPF as an overwhelming sustained sense of exhaustion and a decreased capacity for work.
  • The North American Nursing Diagnosis Association (NANDA) defines PPF as an unpleasant symptom that incorporates total body feelings ranging from tiredness to exhaustion creating an unrelenting overall condition which interferes with an individual's ability to function at their normal capacity (Ream 1996).

There are various factors that contribute to PPF in women. To understand and manage PPF, these factors can be classified into three groups: physiological, psychological, and situational/environmental (Lenz 1997). Physiological factors are primarily related to childbirth and some health problems, such as anaemia, thyroid function, and infection/inflammation. Psychological factors contributing to PPF include depression and stress (Campbell 1986). Situational factors that influence PPF include baby-care responsibilities, managing multiple roles, and returning to work.


Description of the intervention

This review will make use of a model proposed by Ko, in which PPF is viewed as being affected by physiological, psychological and situational factors (Ko 2008). Thus, for the purposes of this review, non-pharmacological interventions will be considered to consist of non-medicinal interventions implemented with the purpose of preventing or reducing fatigue in women with PPF by addressing these factors. In keeping with Ko’s model, interventions are classified according to which of these factors they can influence. The types of interventions included in this review will be limited to those outlined in the model as follows.

  1. Exercise intervention.
  2. Cognitive behavioural therapy (CBT) or self-care intervention.
  3. Telephone Intervention.
  4. Relaxation.


How the intervention might work

It is believed that physiological, psychological, and situational factors are related to PPF (Pugh 1993). Healthcare providers are expected to instigate certain strategies in order to reduce fatigue in postpartum women. Of the available strategies, many are non-pharmacological. For example, researchers reduced physical fatigue in postpartum women with an alternative pushing technique applied during the second stage of labour, as common pushing techniques may be a cause of PPF (Chang 2010; Jacobson 2008; Lai 2009). Other examples address fatigue through the use of structured exercise programs (Dritsa 2008; Ko 2008).


Why it is important to do this review

Postpartum fatigue is the most common unpleasant condition occurring during the postpartum period. Research has shown that 50% to 54% of postpartum mothers experience PPF (Ansara 2005; Glazener 1995) and that symptoms can persist for long periods of time. For example, Parks measured fatigue at five time points beginning 24 hours after delivery and ending 18 months postpartum, with results indicating that 52% of the 229 women enrolled were persistently fatigued from birth to 18 months (Parks 1999).

Often, exhibited symptoms include comfortless, troublesome or odious feelings, physical or mental weariness and exhaustion. Postpartum fatigue can lead to a decrease in functional abilities and poor quality of life (Ream 1996). Postpartum mothers rank fatigue among the top five major concerns during the postpartum period (Milligan 1990). Fatigue has the potential to adversely affect the health of postpartum mothers, their capacity to cope with parenting, and the developing mother-infant relationship (Pugh 1993). It does not appear to resolve at the end of the traditional six-week postpartum period. Unrelieved PPF (a persistent PPF) has been identified as a factor in the development of postpartum depression (Parks 1999).

Despite the obstacles related to definition and measurement, a handful of nurse researchers have begun testing interventions to decrease PPF, and some limited success has been achieved (Milligan 1996; Pugh 1998; Troy 2003). However, the comparison of non-pharmacological interventions for the prevention/reduction of PPF across studies has rarely been discussed. Therefore, we intend to undertake this review to assess the effectiveness of non-pharmacological interventions in reducing the intensity of PPF. Reviewing the current state of knowledge will help to provide guidance for future research and possibly identify promising interventions worthy of further study.



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

  1. To assess the effectiveness of non-pharmacological interventions with the purpose of reducing the intensity of fatigue in mothers during the postpartum period.  



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

Criteria for considering studies for this review


Types of studies

Randomised controlled trials and quasi-randomised controlled trials treating fatigue in postpartum mothers will be included in this review. We will also include cluster-randomised trials. We will not include studies reported only in abstract form or studies using a cross-over design.


Types of participants

Participants will be women who developed postpartum fatigue (PPF) within the first six weeks postpartum.


Types of interventions

Any form of non-pharmacological intervention that can be classified by Ko's model (Ko 2008) and is intended to reduce PPF compared with any form of usual or standard postpartum care.


Types of outcome measures


Primary outcomes

  1. Postpartum fatigue (PPF) (as defined by NANDA-I 2008) experienced during the first six weeks following birth.

As might be expected given such a complex phenomenon, many rating scales have been developed to measure fatigue, such as Dittner 2004. Scales may be unidimensional or multidimensional.

Unidimensional scales

Multidimensional scales

As PPF is the main outcome of this review, other measures that have been employed specifically to determine PPF might also be encountered. The following is the list of PPF-specific instruments.


Secondary outcomes

  1. Depression
  2. Quality of life
  3. Physical functioning
  4. Maternal anxiety and stress
  5. Women's experiences and views: satisfaction

As fatigue is a symptom, its presence and characteristics can only be confirmed through patient-reporting. However, there remains no “gold standard” of fatigue severity available to validate fatigue scales, nor can these measures distinguish fatigue related to physical exertion, emotional stress, pain, sleep disturbance, depression or because the concept of fatigue is poorly understood (Milligan 1997). Therefore, lack of clarity is compounded by the difficulties associated with assessment, making comparisons between trials a complex affair. In order to appreciate the current research, we need to consider individual aspects of fatigue.

Thus, in this review, we will endeavour to examine a single dimension of fatigue, namely intensity. This dimension was chosen as it has perhaps the most well-developed science behind it, suggesting that if any conclusion can be reached, it might be found here. Furthermore, several scales and checklists have been developed to measure this dimension, examples of which include the Brief Fatigue Inventory (BFI) (Mendoza 1999) and the Fatigue Severity Scale (FSS) (Krupp 1989).

Given the current state of knowledge of fatigue, the available scales and checklists are all necessarily subjective. With such a wide spectrum of assessment tools in use, any attempt to directly compare studies will be problematic. Thus, in this review we will make use of the individual study outcomes for comparison across studies categorised into each subgroup.


Search methods for identification of studies


Electronic searches

We will contact the Trials Search Co-ordinator to search the Cochrane Pregnancy and Childbirth Group’s Trials Register. 

The Cochrane Pregnancy and Childbirth Group’s Trials Register is maintained by the Trials Search Co-ordinator and contains trials identified from:

  1. monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
  2. weekly searches of MEDLINE;
  3. weekly searches of EMBASE;
  4. handsearches of 30 journals and the proceedings of major conferences;
  5. weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.

Details of the search strategies for CENTRAL, MEDLINE and EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group.

Trials identified through the searching activities described above are each assigned to a review topic (or topics). The Trials Search Co-ordinator searches the register for each review using the topic list rather than keywords. 

In addition, we will search CINAHL, PsycINFO, and UMI ProQuest Digital Dissertations using the search detailed in Appendix 1.


Searching other resources

In an effort to identify unpublished studies, we will contact researchers who have previously studied in the area of PPF.

We will not apply any language restrictions.


Data collection and analysis


Selection of studies

Two review authors (Kanittha Volrathongchai and Somsakhool Neelasmith) will independently screen abstracts of studies from the literature searches for inclusion in the review. Review authors will not be blinded to authors, institutions, journals, or results. A third review author (Jadsada Thinkhamrop) will be consulted if disagreements cannot be resolved.


Data extraction and management

To assist with data extraction and management, a data extraction form will be designed. For eligible studies, two review authors will extract the data using the agreed form. Discrepencies will be resolved through discussion or, if required, by consultation with a third review author. The resulting data will be entered into the Review Manager software (RevMan 2011) and checked for accuracy.

If information regarding any of the above is unclear, an attempt will be made to contact authors of the original reports to provide further details.


Assessment of risk of bias in included studies

Two review authors will independently assess risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We will resolve any disagreement by discussion or by involving a third review author.


(1) Random sequence generation (checking for possible selection bias)

For each included study, we will describe the method used to generate the allocation sequence in sufficient detail to allow an assessment of whether it should produce comparable groups.

We will assess the method as:

  • low risk of bias (any truly random process, e.g. random number table; computer random number generator);
  • high risk of bias (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);
  • unclear risk of bias.   


 (2) Allocation concealment (checking for possible selection bias)

For each included study, we will describe the method used to conceal allocation to interventions prior to assignment and we will assess whether intervention allocation could have been foreseen in advance of, or during recruitment, or changed after assignment.

We will assess the methods as:

  • low risk of bias (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);
  • high risk of bias (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);
  • unclear risk of bias.   


(3.1) Blinding of participants and personnel (checking for possible performance bias)

For each included study, we will describe the methods used, if any, to blind study participants and personnel from knowledge of which intervention a participant received. We will consider that studies are at low risk of bias if they were blinded, or if we judge that the lack of blinding would be unlikely to affect results. We will assess blinding separately for different outcomes or classes of outcomes.

We will assess the methods as:

  • low, high or unclear risk of bias for participants;
  • low, high or unclear risk of bias for personnel.


(3.2) Blinding of outcome assessment (checking for possible detection bias)

For each included study, we will describe the methods used, if any, to blind outcome assessors from knowledge of which intervention a participant received. We will assess blinding separately for different outcomes or classes of outcomes.

We will assess methods used to blind outcome assessment as:

  • low, high or unclear risk of bias.


(4) Incomplete outcome data (checking for possible attrition bias due to the amount, nature and handling of incomplete outcome data)

For each included study and for each outcome or class of outcomes, we will describe the completeness of data including attrition and exclusions from the analysis. We will state whether attrition and exclusions were reported and the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes. Where sufficient information is reported, or can be supplied by the trial authors, we will re-include missing data in the analyses which we undertake.

We will assess methods as:

  • low risk of bias (e.g. no missing outcome data; missing outcome data balanced across groups);
  • high risk of bias (e.g. numbers or reasons for missing data imbalanced across groups; ‘as treated’ analysis done with substantial departure of intervention received from that assigned at randomisation);
  • unclear risk of bias.


(5) Selective reporting (checking for reporting bias)

For each included study, we will describe how we investigated the possibility of selective outcome reporting bias and what we found.

We will assess the methods as:

  • low risk of bias (where it is clear that all of the study’s pre-specified outcomes and all expected outcomes of interest to the review have been reported);
  • high risk of bias (where not all the study’s pre-specified outcomes have been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported);
  • unclear risk of bias.


(6) Other bias (checking for bias due to problems not covered by (1) to (5) above)

For each included study, we will describe any important concerns that we might have regarding other possible sources of bias.

We will assess whether each study was free of other problems that could put it at risk of bias:

  • low risk of other bias;
  • high risk of other bias;
  • unclear whether there is risk of other bias.


(7) Overall risk of bias

We will make explicit judgements about whether studies are at high risk of bias according to the criteria given in the Handbook (Higgins 2011). With reference to (1) to (6) above, we will assess the likely magnitude and direction of the bias and whether we consider it is likely to have had an impact on the findings. We will explore the impact of the level of bias through undertaking sensitivity analyses (see Sensitivity analysis).  


Measures of treatment effect


Dichotomous data

For dichotomous data, we will present results as summary risk ratio with 95% confidence intervals. 


Continuous data

For continuous data, we will use the mean difference if outcomes are measured in the same way between trials. We will use the standardised mean difference to combine trials that measure the same outcome, but use different methods.  


Unit of analysis issues


Cluster-randomised trials

We will include cluster-randomised trials in the analyses along with individually-randomised trials. As described in the Handbook, we will adjust sample sizes using an estimate of the intracluster correlation co-efficient (ICC) either derived from the trial (if possible), from a similar trial or from a study of a similar population. If we use ICCs from other sources, we will report this and conduct sensitivity analyses to investigate the effect of variation in the ICC. If we identify both cluster-randomised trials and individually-randomised trials, we plan to synthesise the relevant information. We will consider it reasonable to combine the results from both if there is little heterogeneity between the study designs and the interaction between the effect of intervention and the choice of randomisation unit is considered to be unlikely.

We will also acknowledge heterogeneity in the randomisation unit and perform a subgroup analysis to investigate the effects of the randomisation unit.


Dealing with missing data

For included studies, we will note levels of attrition. We will explore the impact of including studies with high levels of missing data in the overall assessment of treatment effect by using sensitivity analysis.

For all outcomes, we will carry out analyses, as far as possible, on an intention-to-treat basis. As such, we will attempt to include all participants randomised to each group in the analyses, with all participants being analysed in the group to which they were allocated, regardless of whether or not they received the allocated intervention. The denominator for each outcome in each trial will be the number randomised minus any participants whose outcomes are known to be missing.


Assessment of heterogeneity

We will assess statistical heterogeneity in each meta-analysis using the T², I² and Chi² statistics. We will regard heterogeneity as substantial if the I² is greater than 30% and either the T² is greater than zero, or there is a low P value (less than 0.10) in the Chi² test for heterogeneity. 


Assessment of reporting biases

If there are 10 or more studies in the meta-analysis, we will investigate reporting biases (such as publication bias) using funnel plots. We will assess funnel plot asymmetry visually. If asymmetry is suggested by a visual assessment, we will perform exploratory analyses to investigate it.


Data synthesis

We will carry out statistical analysis using the Review Manager software (RevMan 2011). We will use fixed-effect meta-analysis for combining data where it is reasonable to assume that studies are estimating the same underlying treatment effect (i.e., where trials are examining the same intervention and the trials’ populations and methods are judged sufficiently similar). If there is clinical heterogeneity sufficient to expect that the underlying treatment effects differ between trials, or if substantial statistical heterogeneity is detected, we will use random-effects meta-analysis to produce an overall summary if an average treatment effect across trials is considered clinically meaningful. The random-effects summary will be treated as the average range of possible treatment effects and we will discuss the clinical implications of treatment effects differing between trials. If the average treatment effect is not clinically meaningful, we will not combine trials.

If we use random-effects analyses, the results will be presented as the average treatment effect with its 95% confidence interval, and the estimates of T² and I².


Subgroup analysis and investigation of heterogeneity

If we identify substantial heterogeneity, we will investigate it using subgroup analyses and sensitivity analyses. We will consider whether an overall summary is meaningful, and if it is, use random-effects analysis to produce it.

We plan to carry out the following subgroup analyses.

  1. The effects of sample selection criteria (e.g. women with specific factors, such as age, versus the general population).
  2. The effects of sample selection comorbidity (e.g. women with specific comorbidity, such as type of delivery or medical/obstretical complication, versus the general population).

Subgroup analysis will be restricted to the primary outcome: postpartum fatigue.

We will assess subgroup differences by interaction tests available within RevMan (RevMan 2011). We will report the results of subgroup analyses quoting the χ2 statistic and P value, and the interaction test I² value.


Sensitivity analysis

We will carry out sensitivity analyses on 'postpartum fatigue'. These will include the use of a fixed- or random-effects analysis, omission of studies that did not describe an adequate method of allocation concealment and imputing values for missing data where appropriate.



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

We acknowledge and appreciate the support of The Cochrane Library and Thai Cochrane Network of the Australasian Cochrane Centre.

As part of the pre-publication editorial process, this protocol has been commented on by three peers (an editor and two referees who are external to the editorial team) and the Group's Statistical Adviser.



  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

Appendix 1. Search strategies

CINAHL (1970 to current)

  2. fatigue$.ti,ab
  3. (tire OR tired OR tiredness).ti,ab
  4. exp CHILDBIRTH/
  6. (postpart$ OR post-part$ OR postnatal$ OR post-natal$ OR birth OR childbirth OR child-birth).ti,ab
  8. 1 OR 2 OR 3 OR 7
  9. 4 OR 5 OR 6
  10. 8 AND 9

PsycINFO (1970 to current)

  2. fatigue$.ti,ab
  3. (tire OR tired OR tiredness).ti,ab
  4. exp BIRTH/
  6. (postpart$ OR post-part$ OR postnatal$ OR post-natal$ OR birth OR childbirth OR child-birth).ti,ab
  8. 1 OR 2 OR 3 OR 7
  9. 4 OR 5 OR 6
  10. 8 AND 9

UMI ProQuest Digital Dissertations (1980 to current)

(postpartum or post-partum or postnatal or post-natal or birth or childbirth or child-birth) AND (fatigue or fatigued or tire or tired or tiredness)


Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

The protocol was developed by all the review authors, Kanittha Volrathongchai (KV), Somsakhool Neelasmith and Jadsada Thinkhamrop with equal contribution. KV is the guarantor for the review.


Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

None known.


Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Acknowledgements
  6. Appendices
  7. Contributions of authors
  8. Declarations of interest
  9. Sources of support

Internal sources

  • Thai Cochrane Network of the Australasian Cochrane Centre, Thailand.


External sources

  • No sources of support supplied


Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Acknowledgements
  7. Appendices
  8. Contributions of authors
  9. Declarations of interest
  10. Sources of support
  11. Additional references
Affonso 1990
Ansara 2005
  • Ansara D, Cohen MM, Gallop R, Kung R, Schei B. Predictors of women’s physical health problems after childbirth. Journal of Psychosomatic Obstetrics & Gynecology 2005;26(2):115-25.
Berger 1991
  • Berger PJ, McCutcheon L, Soust M, Walker AM, Wilkinson MH. Electromyographic changes in the isolated rat diaphragm during the development of fatigue. European Journal of Applied Physiology and Occupational Physiology 1991;62(5):310-6.
Campbell 1986
  • Campbell I. Postpartum sleep patterns of mother-baby pair. Midwifery 1986;2(4):193-201.
Chalder 1993
Chang 2010
  • Chang S, Chou M, Lin K, Lin L, Lin Y, Kuo S. Effects of a pushing intervention on pain, fatigue and birthing experiences among Taiwanese women during the second stage of labour. Midwifery 2010; Vol. 27, issue 6:825-31.
Chee 2006
  • Chee MW, Chuah LY, Venkatraman V, Chan WY, Philip P, Dinges DF. Functional imaging of working memory following normal sleep and after 24 and 35 h of sleep deprivation: correlations of fronto-parietal activation with performance. Neuroimage 2006;31(1):419-28.
Corwin 2005
Corwin 2007
Cottrell 2002
Dittner 2004
Dritsa 2008
  • Dritsa, M Costa DD, Dupuis G, Lowensteyn I, Khalifé S. Effects of a home-based exercise intervention on fatigue in postpartum depressed women: results of a randomized controlled trial. Annals of Behavioral Medicine 2008;35(2):179-87.
Fairbrother 2008
  • Fairbrother N, Hutton EK, Stoll K, Hall W, Kluka S. Psychometric evaluation of the Multidimensional Assessment of Fatigue scale for use with pregnant and postpartum women. Psychological Assessment 2008;20(2):150-8.
Gardner 1991
  • Gardner DL. Fatigue in postpartum women. Applied Nursing Research 1991;4(2):57-62.
Giallo 2011
  • Giallo R, Wade C, Cooklin A, Rose N. Assessment of maternal fatigue and depression in the postpartum period: support for two separate constructs. Journal of Reproductive and Infant Psychology 2011;29(1):69-80.
Glazener 1995
Higgins 2011
  • Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from
Hockey 2000
Hubsky 1992
Jacobson 2008
Ko 2008
  • Ko Y, Yang C, Chiang L. Effects of postpartum exercise program on fatigue and depression during doing-the-month period. Journal of Nursing Research 2008;16(3):177-86.
Kogi 1970
  • Kogi K, Saito Y, Mitsuhashi T. Validity of three components of subjective fatigue feelings. Journal of Science of Labour 1970;46:251-70.
Krupp 1989
  • Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of Neurology 1989;46(10):1121-3.
Lai 2009
  • Lai ML, Lin KC, Li HY, Shey KS, Gau ML. Effects of delayed pushing during the second stage of labor on postpartum fatigue and birth outcomes in nulliparous women. Nursing Research 2009;17(1):62-72.
Lee 1991
Lenz 1997
Lewis 1991
  • Lewis SF, Haller RG. Physiologic measurement of exercise and fatigue with special reference to chronic fatigue syndrome. Reviews of Infectious Diseases 1991;13:S98-S108.
McNeil 2008
Mendoza 1999
Michielsen 2004
  • Michielsen HJ, De Vries J, Van Heck GL, Van Vlierberghe H, Klaas S. Examination of the dimensionality of fatigue: the construction of the Fatigue Assessment Scale (FAS). European Journal of Psychological Assessment 2004;20(1):39-48.
Milligan 1990
  • Milligan R, Parks P, Lenz E. Vision of excellence The decade of the nineties. Proceedings of the West Virginia Nurses' Association Research Symposium, 1990 November 9-11; Greenbrier Hotel, White Sulphur Springs, West Virginia. West Virginia Nurses' Association Research Conference Group, 1990:245-51.
Milligan 1994
  • Milligan RA, Pugh LC. Fatigue during the childbearing period. Annual Review of Nursing Research 1994;12:33-49.
Milligan 1996
  • Milligan R, Lenz ER, Parks PL, Pugh LC, Kitzman H. Postpartum fatigue: clarifying a concept. Scholarly Inquiry for Nursing Practice 1996;10(3):279-91.
Milligan 1997
  • Milligan RA, Parks PL, Kitzman H, Lenz ER. Measuring women's fatigue during the postpartum period. Journal of Nursing Measurement 1997;5(1):3-16.
NANDA-I 2008
  • NANDA International. NANDA-I Nursing Diagnoses: Definitions & Classification. 2009-2011. Oxford: Wiley-Blackwell, 2008.
National Library of Medicine 1999
  • National Library of Medicine. National Library of Medicine - Medical Subject Headings. National Library of Medicine - Medical Subject Headings, 1999.
Parks 1999
  • Parks PL, Lenz ER, Milligan RA, Han H. What happens when fatigue lingers for 18 months after delivery?. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1999;28(1):87–93.
Pearson 1957
Piper 1989
  • Piper B, Lindsey A, Dodd M, Ferketich S, Paul S, Weller S. Development of an instrument to measure the subjective dimension of fatigue. In: Funk S, Tournquist E, Champagne M, Copp L, Weise R, editor(s). Key Aspects of Comfort: Management of Pain, Fatigue and Nausea. New York: Springer, 1989:199-208.
Pugh 1993
Pugh 1998
Pugh 1999
  • Pugh LC, Milligan R, Parks PL, Lenz ER, Kitzman H. Clinical approaches in the assessment of childbearing fatigue. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1999;28(1):74-80.
Ream 1996
RevMan 2011
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.
Rychnovsky 2009
Schwartz 1993
Smets 1995
  • Smets E, Garssen B, Bonke B, De Haes J. The multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. Journal of Psychosomatic Research 1995;39(3):315-25.
Tiesinga 1999
  • Tiesinga LJ, Dassen TWN, Halfens RJG, Heuvel WJA. Factors related to fatigue; priority of interventions to reduce or eliminate fatigue and the exploration of a multidisciplinary research model for further study of fatigue. International Journal of Nursing Studies 1999;36(4):265-80.
Troy 2003
van der Linden 2003
  • van der Linden D, Frese M, Meijman T. Mental fatigue and the control of cognitive processes: effects on perseveration and planning. Acta Psychologica 2003;113(1):45–65.
Yoshitake 1978