Systematic Review of Fatigue Management Among Parturients

Introduction

Childbirth is the natural phenomenon which parturients need to adapting to physical, psychological and social changes and parturients have to lose much more energy for labor process. These will contribute to fatigue (Pugh & Milligan, 1993). The definition of fatigue is self-perception and self-assessment that ability of physical and psychological functioning are decreasing until occurrence of exhaustion. These caused from imbalance between energy receiving and energy consuming and physical and psychological changes are faced with stress (Herdman, 2009).  

The causes of intrapartum fatigue are physical changes when entering the first stage of labor; intermittent uterine contractions (cunningham et al., 2010), contributing to myometrial contraction, decreasing blood circulation, temporary ischemia, lead to uterine exhaustion. When occurring continuously for a long time, as a consequence, it can lead to fatigue (Pugh & Milligan, 1993). During second stage of labor, parturients attempt pushing which is consuming much more energy in order to increase sufficient intra-uterine pressure for moving fetus descending through vaginal canal. If parturient does not receive any compensated energy, it will lead to be more fatigue. For the third stage of labor is the stage of placental expulsion, it requires regularly uterine contraction for expulsion. This stage, parturients are losing some amount of blood (Lowdermilk, Perry, Cashion, & Alden, 2012) and minerals and it will lead to fatigue (Pugh & Milligan, 1993).

Fatigue framework of Pugh and Milligan (1993), three factors related fatigue comprised of physiological, psychological, and situational factors. Firstly, physiological related fatigue are normal physiological changes; contraction pattern, length of labor, and pain response. Secondly, psychological related fatigue are mental state and reaction to childbearing state. Thirdly, situational related fatigue are environment and personal characteristics.

For literatures and evidence-based practices reviews regarding fatigue management among parturients from 1998 to 2013, there were several studies related to fatigue management. Mainly, there were compared the methods of pushing and various interventions. Regarding to initial searching in order to confirm that there was no previous systemic review in the same topic conducted in Cochrance & JBI databases including checking in advanced registered system of JBI database, there was no systemic review and meta-analysis regarding fatigue management among parturients. The researcher team was interested to study because there was no research and evidence-based practice regarding this topic.

Purpose:

To summarize evidence-based practices of intrapartum fatigue management based on quantitative research reported between 1998 and 2013. 

Methods:

The systematic review process followed guidelines developed by the Joanna Briggs Institute (JBI, 2011). The researcher conducted a search from libraries, direct-contact with primary researchers and electronic searching using available and relevant medical and nursing databases as followings: CINAHL,  PubMed, ScienceDirect, Wiley online library, , MIDIRS, Academic Search Elite, ProQuest Medical library, Springer Link, Blackwell synergy, Cochrane systematic reviews database, SIGLE, and Google Scholar.  

Samples in this study were quantitative researches studying fatigue management in parturients including published and unpublished papers, reported in English and Thai between 1998 and 2013. These quantitative researches were selected according to PICO criteria as following: 1) Participant (P): parturients 2) Intervention (I): Fatigue management 3) Comparison/Comparator: control group 4) Outcome (O): fatigue. Moreover, the researches must be RCTs or quasi-experiment with adequate data for reviewing.

Keywords for searching were identified according to PICO criteria as following: 1) Population: parturients, intrapartum women, women during second stage of labor, early postpartum women, immediate postpartum women etc. 2) Intervention: fatigue management, fatigue management program, first stage of labor management, childbirth preparation, positioning, upright position, labor support, nursing support, social support, continuous support in labor, psychosocial support in labor, husband support, female relative support, pushing intervention, pushing technique, bearing-down effort, directed pushing, spontaneous pushing, delayed pushing, coached pushing, uncoached pushing, music therapy, massage therapy, aromatherapy etc. 3) Outcome (O): fatigue, intrapartum fatigue, early postpartum fatigue, immediate postpartum fatigue, maternal fatigue, maternal perception of fatigue, level of fatigue, maternal outcomes, labor outcomes etc.

There were three tools used including 1) Inclusion Criteria Form 2) Critical Appraisal Form: Critical appraisal tools for Randomized Control / Pseudo-randomized Trial (JBI, 2011) 3) Data Extraction Form: Extraction details for Randomized Control trial / Pseudo-randomized trial study information (JBI, 2011).

All identified studies were then reviewed by the researcher and secondary reviewer who then selected relevant studies and appraised and extracted data. These steps were conducted independently. To ensure that the qualities were controlled, the data were compared and if any item was not agreeable, the third reviewer finalized. For this study, the researcher did not have any discrepancy.

Results:

The minimum criteria for appraisal data in order to reviewing inclusion ware 5 out of 10 scores. The systematic search identified a total of 12 studies but 1 study was excluded due to inaccessible full-text. The remaining 11 studies included 8 randomized controlled trials and 3 quasi-experimental studies. Selected studies could not be analyzed by meta-analysis; therefore narrative summary was used for analysis. The researchers analyzed by using descriptive statistics and synthesized methods and outcomes of fatigue management by grouping due to insufficient statistical data.

Methodological analysis of the 11 included studies included 8 studied conducted outside Thailand; 4 studies in the Stated of America, 2 studies in Taiwan, 1 study in Hong Kong, 1 study in the Stated of America and Canada (Multicenter RCT). Almost half of all studies (45.5 %) was published in 2010 – 2013. There were 8 RCTs (72.7%) and 3 quasi-experimental researches (27.3 %). There was 81.8 per cent conducted in large sample size.

In this systematic review revealed that 3 methods of fatigue management were proven to reduce intrapartum fatigue. These methods included 1) pushing methods; 2) fatigue management program comprised of nursing support, positioning and pushing; and 3) music therapy.

For pushing methods could be classified into 2 techniques. Firstly, delayed pushing technique was focused on instructing parturient to start pushing when cervix was fully dilated and she felt fully urge to push, uncontrollably. This technique was to wait until fetal head spontaneous descent without attempting to push. Secondly, spontaneous pushing was focused on which is similar to delayed pushing but there was added intervention which preventing Valsalva maneuver caused excessive pushing.

Fatigue management program during labor stage included nursing support in order to reduce causes and symptoms of fatigue. This program could manage physical and psychological factors related intrapartum fatigue.

Conclusion:

Intrapartum fatigue impacts both physical and psychological health. It also impacts the fetus and neonate. Therefore, parturients who experience fatigue need effective management. In summary, evidence-based recommendations of effective fatigue management among parturients include pushing methods, fatigue management program and music therapy. Pushing methods and fatigue management program can help to reduce physical fatigue because both methods can shorten duration of second stage of labor. Furthermore, fatigue management program also has nursing support which is to help reduce physical and psychological fatigue. For music therapy can help to reduce fatigue because parturient are relaxed and can rest during the first stage of labor contributing to reduce physical and psychological fatigue. Therefore, health professionals, especially nurses who are responsible for taking care of parturients should apply methods of fatigue management proven to reduce intrapartum fatigue as practicality. It's recommended that further research on conducting more experimental research regarding intrapartum fatigue management and replicating primary researches are needed to confirm a reliable body of knowledge. This should be done along with a meta-analysis based on available data.