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N. Wilson and J. J. Lee
ister. The focus of the scale on the severity of the
impact of fatigue symptoms on functioning also
means that it avoids ongoing debates about the
denition of fatigue.
5.8 Treatment ofPost-partum
Fatigue
Despite the high prevalence of fatigue symptoms,
there are few specically developed options
available to clinicians wanting to treat postpartum fatigue [149–151]. To date, only a handful of interventions have been trialled and have
had mixed results with relieving fatigue skills.
The interventions trialled to date fall into three
classes: (1) psycho-behavioural interventions, (2)
exercise and complementary medicine interventions, and (3) interventions designed to help parents manage distress and fatigue symptoms in the
context of infant-settling difculties. Below, the
efcacy of each class of intervention is briey
reviewed, but pharmaceutical and medical treatments for clearly identiable medical causes of
fatigue such as anaemia, infection, and thyroid
dysfunction are excluded [152].
5.8.1 Psycho-Behavioural
Interventions forMaternal
Fatigue
Overall, there has been little success of treatments using psychological and behavioural principles in managing fatigue. The rst intervention
ever trialled for post-partum fatigue was a selfhelp intervention for parents called the Tiredness
Management Guide (TMG), adapted from treatment guidelines for cancer-related fatigue [69,
153], that aimed to help promote self-care and
communication that would assist with increasing
support. A trial of the TMG found no differences
in fatigue compared to a control group between 2
and 6weeks post-partum [153]. The TMG may
be ineffective due to its long format and reliance
on its users to implement the techniques without
any guidance [153, 154]. A subsequent review of
the TMG’s written content found that women
rated a majority of the suggested techniques as
irrelevant to their needs in the post-partum context [154]. Subsequently, the more comprehensive Wide-Awake Parenting (WAP) intervention
was developed and trialled in Australia.
The WAP protocol involved women with
infants aged 0–7 months in the community
receiving a telephone-based treatment, a written
version of the treatment, or being part of a waitlist control group [149, 151]. The telephone and
written treatments used a specially developed
model of energy conservation and restoration
drawn from cognitive behavioural and selfregulation theory to reduce fatigue and help
women to develop strategies to renew their
energy levels [149, 151]. In the WAP trial, women
assigned to the telephone group reported more
intention to engage in healthy behaviours and
higher self-efcacy compared to women in the
written intervention or control groups. However,
there was no difference in fatigue levels after
6 weeks of participation [151]. The authors of
WAP hypothesised that the relatively short duration of the intervention, the persistent nature of
fatigue, and moderate levels of fatigue in their
sample could explain the lack of efcacy of the
WAP protocol in the trial [151].
Doering and Dogan [155] piloted another
intervention called the Helping U Get Sleep
(HUGS). The HUGS intervention is specically
designed to address sleep and fatigue difculties
in the rst 2–3 weeks after birth by using selfmanagement to reduce fatigue. The intervention
involved a professional nurse facilitating participants’ ability to engage in self-management
through a repeated process of evaluating participant-initiated goals that helped them manage
fatigue and the steps taken to achieve those goals
[155]. An initial pilot has shown some promising
results, with women from a socio-economically
disadvantaged background in the HUGS intervention reporting substantial reductions in fatigue
between 2 and 9weeks post-partum. Furthermore,
women participating in the HUGS intervention
reported fatigue levels approximately 50% lower
at 9weeks post-partum than women in an active
control group, despite the women in the HUGS
group having higher levels of fatigue at baseline
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measurement [155]. Further research is still
required to determine if the HUGS intervention
pilot results are replicable and can be applied
later than the rst few weeks post-partum, and to
determine if the changes last longer than a few
weeks.
More recently, Gholami and Mohammadirizi
[156] compared the efcacy of face-to-face and
electronic delivery of an intervention that focused
on helping women with managing fatigue, compared to a control condition in the rst 6weeks
post-partum. Both versions of their intervention
focused on providing relaxation techniques,
developing realistic expectations about maternal
sleep, energy conservation techniques, and planning opportunities for rest. They reported similar
signicant reductions in fatigue for women in
both the face-to-face and e-learning conditions at
4 and 9weeks post- partum compared to women
in the control group [156]. However, while these
differences were statistically signicant, the
magnitude of the change reported was quite small
and may not be reliable or clinically meaningful.
5.8.2 Exercise andComplementary
Medicine Interventions
Like the psychologically based treatments, nonpsychological and non-pharmacological therapies have also had mixed results in treating
post- partum fatigue. Exercise programmes for
women in the early post-partum period showed
signicant reductions in both physical and mental fatigue compared to control conditions in one
community study [157], reductions in physical
but not mental fatigue among post-partum women
with elevated depressive symptoms in a second
study [158], and no differences in a third community study [159].
Other interventions in the form of laughter
therapy and drinking herbal teas have also
reported mixed results. Participation in group
laughter therapy sessions led to lower average
fatigue levels in the laughter therapy group compared to a control group after four sessions [160].
Studies in Taiwan have investigated the efcacy
of herbal teas in reducing post-partum fatigue
between 6 and 10 weeks after birth. One study
found a reduction in fatigue within a group
assigned to drink lavender tea compared to the
control group after controlling for baseline differences in fatigue [161], while another study found
no effect of drinking chamomile tea [162]. Young
and Gryder [163] explored the impact of the
increasingly popular practice of human maternal
placentophagy on fatigue levels. In their trial,
they found no difference between fatigue scores
at 4 days, 1 week, and 3 weeks post- partum
among women consuming processed encapsulated placenta compared to women in the placebo
condition.
5.8.3 Management ofUnsettled
Infant Behaviour
Another form of intervention that has shown
some efcacy in reducing maternal fatigue is
through the management of unsettled infant
behaviour (UIB). UIB is a technical term used to
describe the behaviour of babies that (1) parents
are concerned about; (2) parents nd difcult to
live with; and (3) clinicians nd hard to treat, as
there is no identiable cause [73, 164]. UIB is
common, occurring among up to one in ve
infants, and usually involves some combination
of persistent and inconsolable crying, sleep difculties, short sleep periods, and frequent night
waking [73, 164, 165].
Thome and Alder [166] trialled a telephonebased cognitive behavioural therapy (CBT) treatment for both post-partum fatigue and distress for
women in Iceland between 4 and 6months postpartum reporting UIB and experiencing elevated
depressive symptoms. In their trial, women in the
telephone intervention group received ve telephone calls on managing fatigue, distress, and
UIB.After the calls, these mothers reported less
fatigue and depression at the end of the study
compared with the mothers receiving standard
care [166].
In Australia, admission to specialist residential services dedicated to helping parents is available for parents and their infants when parents
are having difculty managing UIB and experi-
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N. Wilson and J. J. Lee
encing fatigue and psychological distress [73].
These programmes provide respite opportunities,
group psychoeducational training on managing
infant settling, and multidisciplinary care in an
intensive short-term residential programme [73].
Through the admission, the aim is to help parents
establish more sustainable infant “feed-playsleep” routines upon discharge that lead to less
infant and parental fatigue and distress [73].
Fisher and Feekery [167] found that women with
infants ranging from 4 to 12 months attending
one of these specialist programmes in Australia
experienced a signicant reduction in fatigue levels 1 month after admission, and at 6 months
post-admission. Fisher and Feekery [167] also
found similar signicant reductions in depressive, anxiety, anger, and confusion symptoms.
Other studies at the same or other sites in
Australia (these programmes are available in
most major cities) have also found signicant
improvements in infant’s sleep behaviour, maternal-infant bonding, and other mental health
symptoms that are often co-morbid with postpartum fatigue and may perpetuate problems
with fatigue. These include objective psychomotor performance, demoralisation, daytime sleepiness, depression, anxiety, and stress symptoms
[121, 167–169].
where there are well-developed protocols for the
treatment of post-partum depression. Based on
the research ndings to date, it seems that interventions that focus on helping women with
unsettled infant behaviour may have the most
efcacy in improving fatigue, compared to the
lower intensity self-help guides and psychobehavioural interventions. There is also limited
evidence for the effectiveness of the complementary medicine approaches. A summary table is
given below of the current treatments for postpartum fatigue. It is also possible that some of
these forms of treatment (e.g. nurse-guided psychoeducation on fatigue management) may also
be effective in reducing treatment during pregnancy, but there is currently insufcient evidence
to draw any strong conclusions yet (Table5.4).
Key Points
Current evidence suggests that clinician-guided
treatments that help women improve their infantsettling abilities and/or manage their own fatigue
appear to have the most efcacy in reducing postpartum fatigue.
5.8.5 Interactions withOther Forms
ofSurgical Treatment
5.8.4 Best Current Options
forTreatment
Currently, there are no readily available resources
(e.g. a treatment manual) for clinicians (psychologists, psychiatrists, nurses, midwifes, etc.) to
implement an evidence-based treatment for postpartum fatigue, with demonstrated effectiveness
from a randomised control trial. This is a contrast
Table 5.4 Currently effective treatments for post-partum fatigue
Evidence of effectiveness
Nurse-guided psychoeducation on fatigue
management (face-to-face, online, or telephone)
Telephone-based infant settling programmes
Residential infant settling programmes
Laughter group participation
Given that this volume is about post-maternity
body changes, including potential surgical
reshaping procedures post-pregnancy, the interaction between the treatment of fatigue and other
treatments such as abdominoplasty or mastopexy
can be considered. This area is yet to be considered specically in the post-partum fatigue
research. Furthermore, the relationship between
perinatal fatigue and body image has yet to be
researched. However, we do know that the corre-
Mixed evidence of
effectiveness No evidence of effectiveness
Exercise programmes
Herbal tea
consumption
Self-study psychoeducation on
fatigue management
Maternal placentophagy
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lational relationship between perinatal depressive
symptoms and increased body image concerns
appears to be at its strongest at 6 months postpartum, a time that also tends to involve elevated
post-partum fatigue [48].
Given the high prevalence of fatigue in the
rst 12months post-partum, the authors consider
that in the absence of any current ndings, it
seems that at least several months take place after
the birth before any surgery is scheduled; this
will likely allow fatigue levels to have a chance to
reduce prior to the commitment to surgery.
Additionally, prior to conducting any surgery, clinicians would also be wise to use one of the brief
measures of fatigue (e.g. FSS or FAS) mentioned
above in Sect. 5.7. A thorough assessment of
fatigue and depressive symptoms can allow a clinician to consider if fatigue and/or depressive
symptom interventions (e.g. infant settling, cognitive behavioural therapy) should be considered
rst prior to undertaking surgery.
5.9 Conclusion
The perinatal period is a challenging period for
many women, as they adapt to the many physical
changes. The disruption to sleep and ongoing
fatigue from caregiving and adjustment to childbirth leave women vulnerable to more serious
mental health difculties such as depression,
which can also then worsen both fatigue and
sleep disturbance. This chapter has focused on
the widespread but somewhat overlooked psychological phenomenon of prenatal and post-partum fatigue. While prenatal fatigue is less well
understood, there is a growing body of evidence
that post-partum fatigue is highly prevalent and,
for a minority of women, persists and has a substantial impact on their ability to adjust following
childbirth.
This chapter has identied that there are biopsycho- social models that provide a good explanation of how post-partum fatigue is triggered
and then persists. The research has also clearly
differentiated post-partum fatigue from depression and identied that while there is some over-
lap, they are distinct experiences, with distinct
symptoms that can be claried in clinical settings. There are also some widely available reliable and valid measures that can be used in
clinical and research settings to measure postpartum fatigue. These post-partum measures of
fatigue may also prove to be useful for measuring
fatigue during pregnancy with additional future
validation.
Finally, while there are not specic treatments
available, there is a small but growing body of
evidence that suggests that infant settling-focused
interventions may be one of the most effective
ways to assist women reduce their post-partum
fatigue symptoms during this period. Overall,
while there is much to do in this area, we hope
that this chapter provides a useful stepping stone
for professional working in this area to better
understand this phenomenon.
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