The Journal of Nursing Research h VOL. 26, NO.
5, OCTOBER 2018
Downloaded from https://journals.lww.com/jnr-twna by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3XLe684GKHSWSPs4K0vGEr/RvT3R0+CkPU0O2leLpUIyHgWtd/lpM0g== on 06/27/2019
ORIGINAL ARTICLE
Factors Influencing Postpartum Fatigue in
Vaginal-Birth Women: Testing a Path Model
Ching-Hsing HSIEH1* & Chien-Lan CHEN2 & Tan-Ju HAN3 & Pei-Ju LIN4
Hui-Chun CHIU5
ABSTRACT
Background: Postpartum fatigue is a very common com-
plaint among postpartum women. Although current evidence
indicates that several factors (e.g., parity, epidural analgesia,
perineal trauma, perineal pain, and longer second stage of
labor) are associated with postpartum, not enough is known
about the relationships among these physical factors simul-
taneously and how they contribute to the development of
postpartum fatigue. Increased awareness of the complex rela-
tionships among these factors will help nurses assess, prevent,
and alleviate postpartum fatigue.
Purpose: The aims of this study were to test a model of factors
that influence postpartum fatigue and to estimate the direct and
indirect effects of these factors on postpartum fatigue in
vaginal-birth women.
Methods: The hypothesized model of the factors that influence
postpartum fatigue after vaginal birth was developed based on
previous studies. This study used a cross-sectional correlational
design and convenience sampling. The Visual Analog Scale for
Pain was used to measure postpartum perineal pain, and the
Postpartum Fatigue Scale was used to assess postpartum
fatigue via a structured, self-report questionnaire. Data analysis
included descriptive statistics, Pearson’s correlation coeffi-
cients, and path analysis.
Results: This study evaluated 326 healthy postpartum women
within the first day after vaginal birth. Participants ranged from
20 to 43 years old, and 50.9% were primiparous. The model of
the factors influencing postpartum fatigue after vaginal birth
showed a good fit with the empirical data. Parity and the use
of epidural analgesia predicted the duration of the second
stage of labor, and the degree of perineal trauma predicted
perineal pain. Participants who had experienced longer dura-
tions of the second stage of labor and more perineal pain
reported higher levels of early postpartum fatigue.
Conclusions/Implications for Practice: It is suggested that
maternal nurses should better understand postpartum fa-
tigue, take precautions to decrease perineal pain, and pay
more attention to the longer duration of the second stage of
labor to minimize postpartum fatigue, increase patient
comfort, and improve the quality of perinatal care.
KEY WORDS:
vaginal birth, perineal pain, the second stage of labor,
postpartum fatigue.
332
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Introduction
Postpartum fatigue is a very common complaint among
postpartum women, with 88.5% of vaginal-birth women
expressing this complaint in a recent study (Kilic et al.,
2015). Postpartum fatigue begins soon after giving birth
and may become progressively more severe due to a
negative, overwhelming sense of exhaustion and subjective
feelings of distress. Postpartum fatigue may be a result of
new mothers’ implementation of and adjustment to their
new roles and family functions. It is a predictor of perceived
stress and may also be related to the development of
postpartum depression during the early postpartum period.
It may harm interpersonal relations, make it difficult to
continue baby care activities (Lai, Hung, Stocker, Chan, &
Liu, 2015), reduce the new mother’s sense of comfort,
undermine her quality of life, affect breast milk production,
and reduce breast feeding intention and efficacy (Taylor &
Johnson, 2013). Therefore, postpartum fatigue has gained
much attention among those interested in postpartum care
and research (Taylor & Johnson, 2010), and studies
continue to examine fatigue in childbearing women (Kilic
et al., 2015).
Factors that have been shown to be significantly associ-
ated with higher levels of postpartum fatigue include
perineal trauma, perineal pain, and longer labor (Dudley,
Kettle, & Ismail, 2013; East, Sherburn, Nagle, Said, &
Forster, 2012; Taylor & Johnson, 2010; Tzeng, Yang, Kuo,
Lin, & Chen, 2017). Troy (2003) described the causes of
postpartum fatigue, which include physical factors such as
length of labor, type of delivery, wound/episiotomy healing,
pain, and breastfeeding. The perineal pain resulting from
perineal trauma is a subjective feeling that is commonly
reported by women in the early days after vaginal birth.
The frequency of perineal pain among vaginal-birth women
was 92% on the first postpartum day (Kuo, Yang, Kuo,
Tseng, & Tzeng, 2012; Macarthur & Macarthur, 2004).
Women with second-degree or severe perineal trauma
1
RN, PhD, Associate Professor, School of Nursing, Chung Gung
University of Science and Technology & 2BSN, RN, Head Nurse,
Department of Nursing, Linkou Chang Gung Memorial Hospital &
3
BSN, RN, Assistant Head Nurse, Department of Nursing, Linkou
Chang Gung Memorial Hospital & 4BSN, RN, Department of
Nursing, Linkou Chang Gung Memorial Hospital & 5ADN, RN,
Department of Nursing, Linkou Chang Gung Memorial Hospital.
Postpartum Fatigue in Vaginal-Birth Women
reported greater perineal pain (Dudley et al., 2013; East et al.,
2012). East et al. (2012) conducted a study on 215 Australian
women within 72 hours of vaginal birth and found that
89.7% experienced mild-to-severe postpartum perineal pain
during daily activities such as walking, sitting, and getting up
from bed. For these women, perineal pain is almost unbearable
and affects their willingness to care for and breastfeed their
babies, which may then contribute to depression or mental
exhaustion (Way, 2012). Primiparous vaginal-birth women
reported more perineal pain and severer perineal trauma
than multiparous women. Nijrolder, van der Windt, Twisk,
and van der Horst (2010) found that improvement in pain
levels reduced fatigue.
The current and traditional definition of the second stage
of labor begins with the complete dilatation of the cervix and
ends with the birth of the newborn. In prior studies, women
have expressed feelings of exhaustion and having insufficient
control of their own birth processes and that they experi-
enced negativity and difficulties during prolonged labor
(Nystedt, Högberg, & Lundman, 2006). A longer second
stage of labor may cause higher postpartum fatigue (Lai,
Lin, Li, Shey, & Gau, 2009). A study performed by Schiessl
et al. (2005) showed that nulliparity and epidural analgesia
were the strongest risk factors for a prolonged second stage
of labor in a study of 1200 women who delivered vaginally.
In addition, the Valsalva pushing technique is widely used
during the second stage of labor. With this technique,
women are instructed to take a deep breath at the beginning
of a uterine contraction and then to hold their breath and
push long and hard, even if they do not feel an urge to push.
This pushing technique has been associated with increased
maternal fatigue (Chang, Chou, et al., 2011), greater perineal
trauma, and adverse fetal acidemia or deoxygenation (Roberts
& Hanson, 2007). These findings indicate interrelationships
among the factors that are associated with higher levels of
postpartum fatigue.
Understanding the factors that influence postpartum
fatigue and evaluating the situations of postpartum women
to enhance their comfort during hospitalization are very
important for nurses, postpartum women, and their families.
While acknowledging the complexity of factors that influ-
ence postpartum fatigue, the hypothesized model has been
Figure 1. The hypothesized model of the factors influencing postpartum fatigue after vaginal birth.
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 26, NO. 5, OCTOBER 2018
created by the authors based on the literature. The purposes of
this study were to test the hypothesized model of factors and
to estimate the direct and indirect effects on factors influenc-
ing postpartum fatigue in vaginal-birth women (Figure 1).
According to the model, the following three hypotheses were
assessed:
1. Epidural analgesia and parity influence the duration
of the second stage of labor.
2. Parity influences perineal trauma, and perineal trauma
influences perineal pain.
3. The duration of the second stage of labor and perineal
pain influence postpartum fatigue.
Methods
Sample and Sampling Methodology
This study used a cross-sectional correlational design. A con-
venience sample of women was recruited from two postpartum
wards in hospitals in northern Taiwan during the study period.
The participants were all healthy postpartum women who were
older than 20 years old, had given birth at term (Q 37weeks of
gestation), and had given birth to a healthy infant. Postpartum
women with health problems such as postpartum hemorrhag-
ing or anemia, hypertension or hypotension, diabetic mellitus,
fever, heart disease, or a history of depression and those who
had delivered twins were excluded. O’Rourke and Hatcher
(2013) recommended that a minimum sample size of 200 is
required to show statistical significance for path analysis.
This study included 326 participants, which is significantly
above this minimum required sample size.
Data Collection Process
This study received approval from the hospital institutional
review board (102Y3041B). Before recruitment and data
collection, approval to conduct the study was obtained from
the hospitals. To avoid bothering nonparticipants’ rest after
childbirth, potential participants were recruited when they
were admitted to the hospital before childbirth. Women who
met the selection criteria were asked if they would like to
participate in this study. Next, the objective of the study, the
333
The Journal of Nursing Research
anonymity and confidentiality of the participants’ identities,
and the data collection methods were explained to the potential
participants. After childbirth, the potential participants were
assessed against the inclusion and exclusion criteria in the
postpartum wards. All of the participants signed an informed
consent form, and data were collected after giving birth.
Participants were awake and completed the 15- to 20-minute
questionnaire in the presence of family members in the post-
partum wards on the first postpartum day after childbirth.
The participants were free to withdraw from the study and
to refuse to respond to any questions at any time, which
would not affect their rights to continue to receive subse-
quent care during their hospitalization. This study took place
over a period of 8 months from March to October 2013.
Instruments
Structured questionnaires were used to collect demographic
and obstetric data. The demographic variables included age,
marital status, educational level, and the primary postpar-
tum care provider. The obstetric variables included parity,
the use of oxytocin to accelerate labor, the use of epidural
anesthesia during labor, the duration of the second stage of
labor, episiotomy use, and the degrees of perineal trauma,
perineal pain, and postpartum fatigue.
The 10-cm Visual Analog Scale (VAS) was used to mea-
sure the intensity of perineal pain. The number 0 on the
left indicated no pain at all, and the number 10 on the
right indicated the highest degree of pain. The participants
determined the number based on their self-perceived
intensity of perineal pain after childbirth. The VAS allows
participants to quantify their pain level quickly and easily.
Milligan, Parks, Kitzman, and Lenz (1997) modified the
30-item Fatigue Symptom Checklist (FSC; Yoshitake, 1978)
as a 10-item FSC, which has been subsequently used to
measure fatigue in postpartum women. The validity of this
10-item FSC was previously evaluated by confirmatory factor
analysis. Taylor and Johnson (2013) used the Postpartum
Fatigue Scale (PFS), which is a 10-item scale that is scored
using a 4-point Likert scale (1 = not at all to 4 = all of the
time), with possible scores ranging from 10 to 40 and higher
scores associated with higher levels of fatigue. The Cronbach’s
! for the PFS was .88 at 1 week postpartum.
The Chinese version of the 10-item PFS was first
translated by a bilingual nursing professor with bicultural
experience. The Chinese version of this scale has been used
to measure postpartum fatigue in Taiwanese women (Ho,
2009; Lai et al., 2009; Lee, 2014). On the basis of the
Chinese version of the 10-item scale, the back-translation
was done by bilingual individuals, establishing both
content and semantic equivalence in our study. The face
validity of the Chinese version of the PFS was ascertained
by 10 postpartum women. These women commented that
they were able to understand the language of the scale and
that it was very easy to read. The Cronbach’s ! for this
scale was .84 in this study.
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Ching-Hsing HSIEH et al.
Data Analysis
The data were analyzed using AMOS 5.0 and SPSS 17.
Statistical significance was set at p G .05. In this study, the
endogenous variables included postpartum fatigue, peri-
neal pain, perineal trauma, and the duration of second
stage of labor, whereas the exogenous variables included
parity and epidural analgesia. The demographic charac-
teristics and obstetric variables were examined as frequen-
cies, percentages, means, standard deviations, minima, and
maxima. Pearson’s correlation was used to test the rela-
tionships among the study variables. Observed relationships
between study variables helped predict an appropriate
model. Path analysis was used to test the hypothesized
model and to specify causal relationships between study
variables (O’Rourke & Hatcher, 2013). The fitness of the
models was determined using the following: chi-square test,
nonnormed fit index, incremental fit index (IFI), relative
noncentrality index, comparative fit index, standardized
root mean square residual, and root mean square error of
approximation (Hu & Bentler, 1999).
Results
Three hundred fifty women were identified from the
medical records of the target hospital. Eighteen women
declined to participant because of lack of sufficient time.
Three hundred thirty-two women (n = 332/350, 94.5%)
agreed to participate and signed the consent forms, but six
of them did not complete one or more of the question-
naires. Thus, 326 participants (n = 326/350, 93.1%)
completed and returned all of the required questionnaires.
All of the participants were given the questionnaires
within the first day after giving birth.
The participants ranged in age from 20 to 43 years (M =
32.26 years, SD = 4.12 years). More than half of the
participants had a university degree or higher (n = 222,
68.1%), and most were married (n = 322, 98.8%).
Approximately half (n = 166, 50.9%) were primiparous,
and 38.7% (n = 126) had used oxytocin. Furthermore,
40.5% (n = 132) used epidural analgesia to lessen the pain
of labor. Most (n = 305, 93.6%) had received episiotomies,
and 21.2% (n = 69) experienced third- or fourth-degree
perineal trauma (Table 1). All of the participants who
reported third- or fourth-degree perineal trauma (n = 69)
had received episiotomies. More primiparous women
(96.4%) than multiparous women (90.6%) had received
episiotomies. In addition, 96.3% (n = 314) of the
participants stated that the baby’s father was the primary
caregiver during the early postpartum period.
The mean score for postpartum fatigue was 14.29 (SD =
3.97) for all participants, with a score of 14.36 (SD = 4.11)
for primiparous women and 14.22 (SD = 3.84) for
multiparous women on the PFS. The mean duration of
the second stage of labor was 47.62 (SD = 45.82) minutes
overall, with an average time of 72.11 (SD = 50.45)
minutes for primiparous women and 22.22 (SD = 19.70)
Postpartum Fatigue in Vaginal-Birth Women VOL. 26, NO. 5, OCTOBER 2018

TABLE 1. duration of the second stage of labor was positively

Social Demographic and Obstetric correlated with perineal trauma (r = .25, p G .01) and
Characteristics (N = 326) epidural analgesia (r = .37, p G .01) and was negatively
correlated with parity (r = j.55, p G .01), and postpartum
Variable n % fatigue was positively correlated with perineal pain (r =
.19, p G .01) and duration of the second stage of labor (r =
Education .12, p G .05). All of the correlations were in the anticipated
High school/lower 63 19.3
direction, supporting a statistical relationship among the
Junior college 39 12.0
University 183 56.1 observed variables.
Graduate school/higher 39 12.0
unanswered 2 0.6
Measurement Model
Marital status
Married 322 98.8 The hypothesized model was tested using a path analysis.
Unmarried 2 0.6 Table 3 shows the data for the goodness-of-fit indices. The
Other 2 0.6 hypothesized model revealed a nonsignificant chi-square
Oxytocin statistic (likelihood ratio # 2 = 9.43, df = 8, p = .31). The
Yes 126 38.7 values of the IFIs, including nonnormed fit index, IFI,
No 200 61.3 relative noncentrality index and comparative fit index,
Epidural analgesia were greater than .95. The standardized root mean square
Yes 132 40.5 residual values of the absolute fit indexes were less than
No 194 59.5 .80, and the root mean square error of approximation
Episiotomy values were less than .60. Overall, all of the data indicated
Yes 305 93.6 an acceptable fit between the data and the model (Hu &
No 21 6.4 Bentler, 1999). Therefore, the hypothesized model was
Degree of perineal trauma supported by the data that were acquired for this study.
No trauma 5 1.5
1st 6 1.8
2nd 246 75.5 Path Analysis Results
3rd 56 17.2 The model testing results are presented in Figure 2. The
4th 13 4.0 model revealed that multiparous women had less perineal
Caregiver trauma (" = j.27, p G .001) and shorter durations of
Baby’s father 314 96.3 second-stage labor (" = j.48, p G .001), whereas women
Other 12 2.7 who had received epidural analgesia had longer durations
Mean SD of second-stage labor (" = .26, p G .001). In addition,
parity was negatively correlated with the use of epidural
Age 32.26 4.12
analgesia (r = j.23, p G .001), indicating that multiparous
Weight gain in pregnancy (kg) 13.43 4.87 women use epidural analgesia at a lower rate than their
Duration of second stage (min) 47.62 45.82 primiparous peers.
Perineal pain 4.57 2.12 The perineal trauma of the participants was positively
Postpartum fatigue 14.29 3.97 correlated with perineal pain (" = .15, p G .01), indicating
that more severe perineal trauma was associated with

minutes for multiparous women. The mean score for

TABLE 2.
perineal pain as measured using the VAS was 4.57 (SD =
2.12) overall, 4.63 (SD = 2.08) for primiparous women and Correlation Matrix of All Study Variables
4.51 (SD = 2.17) for multiparous women.
Variable 1 2 3 4 5 6

1. Postpartum fatigue 1.00

2. Perineal pain .19** 1.00
Relationships Among Variables 3. Duration of the second .12* .02 1.00
The relationships among postpartum fatigue, perineal stage of labor
pain, the duration of the second stage of labor, and the 4. Perineal trauma j.02 .15* .25** 1.00
respective degrees of perinea trauma, epidural analgesia, 5. Epidural analgesia .08 .04 .37** .13* 1.00
and parity were analyzed using Pearson’s correlation
6. Parity j.02 j.03 j.55** j.27* j.24** 1.00
coefficients (Table 2). Perineal pain was positively corre-
lated with the degree of perineal trauma (r = .15, p G .05), *p G .05. **p G .01.

335

Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
The Journal of Nursing Research Ching-Hsing HSIEH et al.

TABLE 3. women (East et al., 2012). This study confirms that perineal
Selected Model Fit Indexes of the pain influences postpartum fatigue directly, with results
Research Model showing that women with more perineal pain have higher
levels of postpartum fatigue, as shown in previous studies
Acceptable (Cappell & Pukall, 2017; Nijrolder et al., 2010; Taylor &
Model Fit Criterion Value Appraisal Johnson, 2013). Most of the participants in this study had
received episiotomies, and these women reported experienc-
Incremental fit indexes
NNFI Close to .95 .987 Good ing relatively higher levels of perineal pain. This finding is
IFI Close to .95 .993 Good supported by previous studies that have associated episiot-
RNI Close to .95 .957 Good omies with greater perineal pain (Chang, Chen, Lin, Chao,
CFI Close to .95 .993 Good & Lai, 2011; Leeman et al., 2009). Many women consider
Absolute fit indexes perineal trauma and stitches as the worst outcome after
SRMR Close to .08 .034 Good childbirth. Macarthur and Macarthur (2004) confirmed that
RMSEA Close to .06 .023 Good women with increased perineal trauma experience greater
perineal pain. Alleviating perineal pain is an important task
Note. The criteria were according to Hu and Bentler (1999). NNFI = in postpartum maternity care. If not properly addressed,
nonnormed fit index; IFI = incremental fit index; RNI = relative noncentrality
index; CFI = comparative fit index; SRMR = standardized root mean square perineal pain may affect postpartum self-care behavior,
residual; RMSEA = root mean square error of approximation. breastfeeding, and wound healing and lead to long-term
negative effects such as incontinence, painful sexual inter-
increased perineal pain. Both perineal pain and the
course, and discomfort when passing urine or feces. There-
duration of the second stage of labor were found to be
fore, future studies should test the effectiveness of nursing
positively correlated with postpartum fatigue (" = .19, p G
interventions in relieving the postpartum pain resulting from
.001; " = .12, p G .05, respectively), indicating that greater
perineal trauma during the early postpartum period.
postpartum perineal pain and longer second stage of labor
This study supports that perineal trauma affects perineal
contributed to higher levels of postpartum fatigue in the
pain directly. Roberts and Hanson (2007) recommended
participants.
maternal positioning and bearing down as strategies to
minimize perineal trauma. During the second stage of labor,
the participants in this study were moved from a labor room
Discussion to a delivery room and thus moved from a hospital bed to a
The model proposed in this study is meaningful, as it shows birthing bed. A semirecumbent lithotomy position was
empirical data for the physiological factors that influence recommended for all women in the birthing bed. Moreover,
early postpartum fatigue as well as explains the direct and the participants were not allowed to freely change positions
indirect effects among study variables. Common childbirth such as assuming upright or lateral positions and thus were
practices among the participants included routinely using kept in the same position throughout the second stage of
episiotomies, the semirecumbent lithotomy position during labor. This limitation of movement made the laboring women
childbirth, epidural analgesia, and the Valsalva pushing feel fatigued and uncomfortable. These birth interventions
technique. These factors are known to influence perineal are contrary to Kopas’ (2014) recommendations that women
trauma, perineal pain, and postpartum fatigue. should be allowed to choose from a variety of positions in
Childbirth is an energy-consuming process, and women which to push and give birth and that the supine position
require adequate rest to recover from fatigue during the should be avoided. Upright positions for birth are more
early postpartum period. However, perineal pain is an comfortable and may increase women’s sense of control.
important factor that affects rest and sleep in postpartum Position changes may also prevent lumbosacral spine and

Figure 2. Standardized estimate of the research path model. *p G .05. **p G .01. ***p G .001.

336

Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
Postpartum Fatigue in Vaginal-Birth Women
lower-extremity nerve injuries (Roberts & Hanson, 2007).
Hence, we recommend that women should be able to change
their position freely in line with their needs and birthing
situation during labor and delivery, rather than being limited
to one position.
Another factor associated with postpartum fatigue is the
use of episiotomies, which influenced many of the partici-
pants in this study. Episiotomy, the most common surgical
procedure performed on childbearing women, describes a
surgical procedure in which an incision is made into the
perineum and vagina to facilitate delivery. In this study, the
primiparous women experienced more severe perineal trauma
than their multiparous peers. Williams, Herron-Marx, and
Knibb (2007) found that women who had received an epi-
siotomy during childbirth consequently felt more perineal
pain and reported a higher incidence of urine incontinence
than women whose perineal trauma occurred spontaneously
as a tear. Seijmonsbergen-Schermers et al. (2013) recom-
mended that the conservative use of episiotomy is likely to
be beneficial for women. A study by East et al. (2012)
focused on postpartum women within 72 hours of vaginal
birth and reported that only 23.7% of the participants had
received episiotomies. Seijmonsbergen-Schermers et al.
reported an episiotomy rate of only 10.8%, in comparison
with the 77.0% rate among Taiwanese women, as reported
by Chang, Chen, et al. (2011). Therefore, attention should
be paid to the routine use of episiotomies in Taiwan and issues
related to postpartum trauma. Chang, Chen, et al. recom-
mended that maternity nurses should cover the advantages and
disadvantages of episiotomies in the prenatal education that
they provide to patients to allow new mothers to make infor-
med decisions and have greater control over their bodies and
birth experiences. Future research and maternal care should
focus on preventing perineal trauma and decreasing the rate of
episiotomies to alleviate perineal pain and discomfort.
The results of this study indicate that parity and epidural
analgesia directly affect the duration of second-stage labor,
which was found to directly affect postpartum fatigue. The
results of this study match those of previous studies, showing
that nulliparous women and women with epidural analgesia
are more likely to have prolonged second stages of labor
(Gimovsky, Guarente, & Berghella, 2017; Hasegawa et al.,
2013). Epidural analgesia is a widely available method to
relieve pain during labor. However, women who receive
epidural analgesia are disempowered by the process of
medicalization, and they may be more likely to receive further
interventions such as instrumental or operative deliveries
(Tamagawa & Weaver, 2012). Therefore, we recommend
that prenatal childbirth classes educate and inform women
about the potential effects of epidural analgesia on labor
progression, particularly for nulliparous women.
Last, the Valsalva pushing technique was widely used
during the second stage of labor in this study. Prins, Boxem,
Lucas, and Hutton (2011) mentioned that women who use
a spontaneous pushing approach are self-directed in their
bearing-down techniques. Birth experiences are much calmer
Copyright © 2018 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 26, NO. 5, OCTOBER 2018
and more relaxed when birth practitioners try to avoid telling
women when to push and let them push when they feel the
urge. Nurses may provide verbal support to help nulliparous
women with spontaneous pushing during the second stage of
labor. Women may use their own power, which imbues them
with much needed confidence and trust in their own body’s
signals to push spontaneously (Borders, Wendland, Haozous,
Leeman, & Rogers, 2013). Lai et al.’s (2009) study of 72
women indicated that nulliparous women with delayed pushing
in the second stage of labor experienced less postpartum fatigue
than women without delayed pushing. Therefore, spontaneous
pushing increased the likelihood of spontaneous vaginal
birth in women who used epidural analgesia.
These findings provide a greater understanding of the
relationships among the study variables. Reducing perineal
trauma and perineal pain and not prolonging the second
stage of labor were both shown to reduce the risk of post-
partum fatigue.
Study Limitations
This study used a convenience sample that included post-
partum women from hospitals in northern Taiwan. No
information is available about the otherwise qualified
women who chose not to participate. Therefore, it is possible
that significant differences exist between the demographic or
basic data of participants and nonparticipants. Random
sampling and different samples from different areas are
recommended to test the generalizability of the results. The
factors of influence that were assessed in this study were
chosen based on previous studies, and other factors may
have explained more of the variance in postpartum fatigue
scores. The findings of this study add to our understanding
of the relationships among the factors that influence early
postpartum fatigue in women after vaginal birth. Further
research, particularly longitudinal studies, may further show
the relationships among relevant variables. A validated
Chinese version of PFS is needed to study postpartum fatigue
in Taiwanese populations. Thus, it is suggested that future
studies assess the psychometric properties of the Chinese
version of PFS.
Nursing Applications
The priority of maternal nursing care for women with post-
partum fatigue on the first postpartum day is to alleviate
patient perineal pain through interventions such as perineal
ice packing and relaxation techniques. Allowing women to
freely change their position and to push spontaneously
during the second stage of labor may be useful strategies to
lessen postpartum fatigue. Nurses may provide prenatal
childbirth classes for pregnant women, particularly for
nulliparous women and their families. Women should be
educated and informed of the potential effects of epidural
analgesia and pushing technique on labor progress. This
study investigated the physiological factors that influence the
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The Journal of Nursing Research
occurrence of postpartum fatigue in women during the
immediate postpartum period. Future studies should explore
other potential factors of influence such as prenatal depres-
sion, anxiety, family support, breastfeeding, infant temper-
ament, and participation in childbirth education. The results
of this study provide guidance to maternal nurses for the
development and testing of interventions for women
experiencing postpartum fatigue.
Conclusions
The model of factors that influence postpartum fatigue among
vaginal-birth women showed good fit indices and was
supported by the empirical data. This study explains that
postpartum perineal pain and duration of the second stage of
labor both affect postpartum fatigue directly. The developed
model offers guidance for designing future nursing practice,
research, and education related to postpartum fatigue.
Acknowledgments
This study was sponsored by a noncommercial grant from
Chang Gung Medical Foundation (CMRPF1D0011),
Taiwan. The authors express their greatest appreciation
to all of the participants.
Accepted for publication: July 10, 2017
*Address correspondence to: Ching-Hsing HSIEH, No. 261, Wenhua
1st Rd., Guishan Dist., Taoyuan City, Taiwan, ROC.
Tel: +886-3-211-8999 ext. 3416;
E-mail: chinghsingesther@hotmail.com
The authors declare no conflicts of interest.
Cite this article as:
Hsieh, C. H., Chen, C. L., Han, T. J., Lin, P. J., & Chiu, H. C. (2018).
Factors influencing postpartum fatigue in vaginal-birth women:
Testing a path model. The Journal of Nursing Research, 26(5),
332Y339. https://doi.org/10.1097/jnr.0000000000000249
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