| 61
Pensar Enfermagem / v.28 n.01 / June 2024
DOI: 10.56732/pensarenf.v28i1.307
Qualitative Original Article)
How to cite this article: Pena BSAN, Santos MAF. Strengths-Based Care: A Postpartum Plan for a Positive
Fourth Trimester Experience. Pensar Enf [Internet]. 2024 Jun; 28(1): 61-73. Available from:
https://doi.org/10.56732/pensarenf.v28i1.307
Strengths-Based Care: A Postpartum Plan for a
Positive Fourth Trimester Experience
Abstract
Introduction
The fourth trimester, or postpartum period, places the woman (newborn and couple) at the
center of family care. In this study, an instrument was developed to enable the postpartum
woman or couple to plan and organize the postpartum period, facilitating adaptation during
this time, guided by Laurie Gottlieb’s theoretical framework on Strengths-Based Nursing
Care.
Objective
The study begins with the research question: What difficulties does the postpartum woman
experience? The objectives are to identify the bio-psycho-social needs of the triad in the first
12 weeks postpartum, the strategies of the postpartum woman or couple to overcome
perceived difficulties, and the items to be included in the postpartum plan from a maternal
perspective.
Methods
A descriptive exploratory study using a mixed-methods approach was conducted with a
questionnaire administered to mothers aged 18 to 39. The study garnered 141 responses that
met the eligibility criteria from April 14 to May 5, 2023. The data collection instrument was
shared via mother groups on social networks (Facebook, Instagram, and WhatsApp).
Content analysis was conducted according to Bardin, employing semantic categorization in
the treatment of qualitative data and statistical analysis of quantitative data.
Results
The study uncovered the difficulties, the needs of the triad in the first 12 weeks, the strategies
or strengths to overcome these difficulties, and the suggested items for the postpartum plan.
Conclusion
The study concludes that the postpartum plan is an innovative concept, as pregnant women
or couples often focus on developing the birth plan, frequently overlooking or undervaluing
the postpartum plan. However, most participants considered planning to be one of the
strengths or strategies for a positive experience in the fourth trimester.
Keywords
Nurse Midwife; Women's Health; Holistic Nursing; Strengths-Based Care; Postpartum
Period.
Berta Susana de Almeida Nunes da Pena
1
orcid.org/0009-0000-9164-6058
Maria Anabela Ferreira dos Santos
2
orcid.org/0000-0002-1675-5227
1
Master's, Nurse at USF Querer Mais, Local Health
Unit Arco Ribeirinho, Member of the Lisbon Nursing
Research, Innovation and Development Center
(CIDNUR), Lisbon, Portugal.
2
Coordinating Professor at Nursing School of Lisbon,
Lisbon. Member of the Lisbon Nursing Research,
Innovation and Development Center (CIDNUR),
Lisbon, Portugal
Corresponding Author:
Berta Susana de Almeida Nunes da Pena
Email: penal@campus.esel.pt
Recebido: 03.01.2024
Aceite: 16.04.2024
62 | Pena, B.
Qualitative Original Article
Introduction
The postpartum period encompasses a series of physical
and psychological changes that occur after childbirth.
1
According to Chauhan and Tadi,
2
it begins following the
expulsion of the placenta and continues until the complete
recovery of various organic systems. This concept is based
solely on anatomical and physiological principles.
According to the definition of the postpartum period by
the General Directorate of Health (DGS),
3
it is a period of
maternal physical and psychological recovery that starts
after birth and lasts up to 6 weeks postpartum.
The World Health Organization (WHO)
4
also considers
the first 6 weeks as the defined duration for the postpartum
period, dividing it into the immediate postpartum (first 24
hours), early postpartum (from the second to the seventh
day), and late postpartum (until the end of the 6th week).
Chauhan and Tadi
2
consider the late phase to last from 6
weeks to 6 months after childbirth.
According to Souza and Fernandes,
5
the postpartum period
can last up to a year, adding a remote period from the 43rd
day to one year postpartum.
The postpartum period is a time of transition, involving
adaptations and physical, biological, familial, and emotional
transformations reflected not only in individual care but
also in the interactions that the woman establishes with her
child, partner, and other family members. This is a moment
of vulnerability where there are needs for social, physical,
emotional, and informational support.
6
Despite being a
phase of the pregnancy-puerperal cycle filled with many
challenges and vulnerabilities, it is often the stage where the
woman receives the least attention and support from health
professionals.
5
The needs felt throughout the postpartum period challenge
healthcare professionals from prenatal care to prepare the
woman for the situations she will experience in this new
phase, as well as working with the family to strengthen
relationships and prepare the support network for the
arrival of the new member. In this sense, it is important to
begin planning for the postpartum period during
pregnancy.
7,8,6
According to Savage,
9
birth planning should
go beyond labor and delivery and include the following
weeks, with early discussions about infant feeding,
postpartum emotional health, the challenges of
parenthood, and postpartum recovery from birth, including
the support network.
7, 9
Continuous postpartum support centered on the woman is
a recommendation from The American College of
Obstetricians and Gynecologists (ACOG),
7
considering
this period as the fourth trimester in which it recommends
that there should be more than one consultation during at
least the first 12 weeks. The fourth trimester concept
refocuses attention on this period, considering the
challenges and needs of the postpartum woman, newborn,
and couple integrated into their family environment.
ACOG also reinforces in the same recommendation the
shared decision-making between the healthcare
professional based on scientific evidence and the
postpartum woman with her experiences and values.
The transition to motherhood develops in four distinct
phases, according to Mercer,
8
where the first phase occurs
during pregnancy and involves bonding with the fetus and
preparing for childbirth and motherhood; the second,
during the first two to six weeks postpartum, is crucial for
postpartum recovery and acquiring knowledge to care for
the baby; the third, between two weeks and four months, is
about adjusting to daily life; and lastly, the fourth phase,
around four months, consists of achieving maternal
identity. The father also goes through a transition process
that begins between the fourth and fifth month of
pregnancy, a time when he starts to feel the first fetal
movements and experiences feelings such as the desire to
be present at childbirth and anxiety about the approaching
moment when the experience of fatherhood develops with
the relationship with the baby in the new routines after
birth.
10
The fourth trimester also encompasses all practices that
simulate the intrauterine environment (swaddling,
shushing, side/stomach position, swinging, and sucking),
resembling an external gestation; it is based on the principle
that the baby needs at least three months of adaptation to
the extrauterine environment, according to Lima et al.
(2017), cited by Sequeira et al.
11
Hannon et al.
12
emphasize the importance of including
health and well-being, not just the absence of morbidity, in
a holistic view of care during this phase of motherhood. A
positive experience of pregnancy, childbirth, and the
transition to motherhood is a highly desirable outcome for
all women. A positive postnatal experience is defined as
one in which women, partners, parents, caregivers, and
families consistently receive information and reassurances
from motivated health professionals. The health, social,
and developmental needs of women and babies are
recognized within a health system that is resourceful,
flexible, and respectful of their cultural context.
4
Strengths-Based Care (SBC) by Laurie Gottlieb
13
takes a
holistic approach that centers on the individuality of the
person, considering strengths and potentials embedded in
their environment. Beyond person-centered care, it is based
on three additional pillars: the empowerment movement,
collaborative partnership, and health promotion and
prevention—which encourage the individual to take
responsibility for their health, recovery, and healing,
according to the author. This theoretical framework is more
than just a model; it is a philosophy with roots
fundamentally in Florence Nightingale's approach to
nursing.
14
For Gottlieb, strengths are “the qualities, skills,
competencies, capabilities, and abilities that are distinct and
separate, coexisting with weaknesses,” which define “the
individuality of the person and give expression to their
humanity.”
13(p.126)
According to the same author, strengths
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DOI: 10.56732/pensarenf.v28i1.307
Qualitative Original Article
can be biological, intra- and interpersonal, and social
(resources and goods), which help individuals cope with
challenges, achieve goals, and integrate these aspects into
the totality of their being, committing to their self-
development. In the author's holistic view, all aspects of a
person—body, thoughts, emotions, consciousness,
spiritual bonds, social relationships, and coping abilities—
work together to make the individual feel complete and
whole. Social resources, which are in the person's
immediate environment, may include finances, family
relationships, religion, community, and similar elements.
13
The person must be aware of available resources to
mobilize and access them.
Strengths-Based Care (SBC) employs positive language
such as strength, energy, challenges, opportunities, and
possibilities, representing a language of hope. It involves a
collaborative relationship in which the nurse and the team,
along with the person and the family, make decisions,
create the plan, and work together to find solutions. The
feelings, thoughts, and experiences of the person are
valued. It focuses on the individual's health and life.
13
According to Gottlieb,
13
when individuals, families, and
communities believe in themselves and focus on the
positive aspects, they are respected; and when they have
resources available to find solutions to their problems, they
are more likely to build a sustainable future for themselves
and their children.
This is evidenced by similarities between this theoretical
model and the philosophy of care of the Nurse Specialist in
Maternal and Obstetric Health (EESMO), where Barradas
et al.
15
emphasize empowerment, woman-centered care,
and the partnership between the woman and the EESMO
nurse from a holistic perspective, giving the nurse the
responsibility to provide care with flexibility and creativity
to empower and support.
In this sense, it is essential to empower the woman, the
couple, and the family for the fourth trimester so that
strategies based on their strengths and potentials can be
created to overcome and minimize the challenges they may
face in a healthy environment.
This study was conducted as part of a Master's Thesis in
Maternal and Obstetric Health Nursing and arose from the
idea of developing a tool to plan and organize the
postpartum period, focusing on low-risk pregnancies and
thereby aiding adaptation during this time. A scoping
review was previously conducted that mapped the evidence
concerning the theme.
The study begins with the research question: What
difficulties do postpartum women experience? The
objectives are to identify the bio-psycho-social needs of the
triad in the first 12 weeks postpartum, the strategies of the
postpartum woman/couple to overcome perceived
difficulties, and the items to be included in the
postpartum plan.
Methods
A descriptive exploratory study using a mixed-methods
approach was conducted. The inclusion criteria included
mothers aged between 18 and 39 at the time of childbirth,
with healthy children born within the last three years.
Exclusion criteria applied to situations where either the
mother or the baby experienced health complications that
required hospitalization beyond the typical postpartum
stay, as these cases have specific needs. Mothers at the
extremes of the reproductive age range were also excluded
as they are considered high-risk pregnancies according to
the modified Goodwin scale.
3
The data collection tool was a questionnaire developed in
Google Forms, featuring both open and closed questions.
It consisted of 53 questions divided into four sections:
sociodemographic data, information about pregnancy and
childbirth as referred to in the questionnaire, details about
the postpartum period, and the postpartum plan.
In October 2022, a questionnaire evaluation was conducted
with eight mothers who met the inclusion criteria to assess
clarity, acceptability, comprehension, and item reduction.
16
This evaluation also involved mothers who are nurse
specialists in maternal health, providing not only the
perspective of a mother but also that of a health specialist.
As a result, semantic validation was performed, which
clarified the language
16
and enhanced the understanding of
the content, with all suggested modifications being
incorporated.
A non-probabilistic convenience sample was chosen
because it allows for a quicker and less costly study, as
noted by Vilelas.
16
The “snowball” sampling technique, or
network sampling, was utilized. The data collection tool
was initially shared through mother groups on social
networks (Facebook, Instagram, and WhatsApp) and
through personal acquaintances with mothers who met the
inclusion criteria. There was a request to further share it
with others who met the criteria from April 14 to May 5,
2023.
In total, 146 responses were obtained, but five
questionnaires (Q9, Q14, Q18, Q21, and Q28) were
excluded because they pertained to situations of
hospitalization in neonatology, resulting in 141 participants
being included.
Statistical analysis of the quantitative data was performed.
Content analysis was carried out according to Bardin.
17
This
involves three phases: pre-analysis; material exploration
and treatment of results; and inference and interpretation.
In the pre-analysis phase, a “floating reading” was
conducted to get an overall idea of the content. Each
questionnaire was assigned a code in the order they were
completed (first questionnaire - Q1).
The material exploration phase, comprising the actual
analysis,
17
was conducted using WebQDA – Qualitative
Data Analysis software and the Microsoft Office Excel
64 | Pena, B.
Qualitative Original Article
software program. Finally, the treatment of the results
obtained and their interpretation took place, where the raw
results were analyzed to produce meaning.
17
This phase
involved the synthesis and selection of results, inferences,
and interpretation.
Categorization facilitates organizing content by grouping
information into categories based on previously established
criteria, which can be semantic, syntactic, lexical, and
expressive.
17
In this context, a table was prepared with
categories, subcategories, and the respective registration
units that determine them and are relevant to the study
objectives. Semantic categorization, which groups by
themes,
17
was employed according to the objectives, the
scoping review, and the theoretical reference to Strengths-
Based Care (SBC) (Table 4).
The data concerning the items for constructing the
postpartum plan were collected through open and closed
questions, thus they were subjected to both qualitative and
quantitative analysis.
In this research, all ethical procedures were strictly adhered
to since the questionnaire was completed anonymously via
Google Forms, ensuring that neither the researchers had
access to the identities of the participants. Informed and
explicit consents were obtained in the questionnaire,
specifically in the introduction in which the study objectives
were presented, ensuring confidentiality, self-
determination, and anonymity. The online nature of the
questionnaire was beneficial for participants as it allowed
them to choose when and where to respond, and their
participation was optional. No risks were identified for the
research subjects.
Results
The results of the study emerged from both closed and
open questions.
The age of the participants at the time of childbirth was
predominantly between 26 and 34 years old (n=99),
followed by 35 to 39 years old (n=33) and 18 to 25 years
old (n=9).
Graph 1 - Distribution of the sample by age at the time of childbirth
(n=141)
Most responses indicated that the postpartum mothers
have a master's degree (42.5%) and a bachelor's degree
(34%), with the lowest level of education being the second
cycle of basic (elementary) education and the highest being
a doctorate.
Regarding their profession, according to the Portuguese
Classification of Professions,
18
42.5% are specialists in
intellectual and scientific professions, followed by 15.5% as
technicians and intermediate-level professionals, and
14.9% in administrative, services, and similar roles. Of the
participants, 19.8% work in the maternal and child health
area.
The majority are Portuguese (97.9%), with two Brazilians
and one South African, married (52.5%), in a common-law
marriage (39.7%), single (7.1%), and one widow. As for the
type of family, the majority are nuclear (82%) (Table 1).
Table 1 – Identification data
Absolute
Frequency
Relative
Frequency
(%)
2. Age at the time of the childbirth referred to in the
questionnaire
18 - 25 years
9
6.4 %
26 -34 years
99
70.2 %
35-39 years
33
23.4 %
3. Education
No schooling
0
0 %
Basic education 1st Cycle - primary
(currently 4th grade)
0
0 %
Basic education 2nd Cycle -
elementary (currently 6th grade)
2
1.4 %
Basic education 3rd Cycle - middle
(currently 9th grade)
2
1.4 %
High school (currently 12th grade)
17
12.1 %
Post-high school (non-degree
technology specialization courses)
3
2.1 %
Higher technical professional course
4
2.8 %
Associate degree (includes former
intermediate courses)
0
0
Bachelor's degree
48
34 %
Master's degree
60
42.5 %
Doctorate
4
2.8 %
Other: Bachelor's degree and
Postgraduate
1
0.7 %
4. Profession
Unemployed
11
7.8 %
Unskilled worker
13
9.2 %
Farmers, Factory Workers, Artisans,
and other Skilled Workers
4
2.8 %
Administrative, Service, and Similar
Staff
21
14.9 %
Technicians and Associate
Professionals
22
15.5 %
Specialists in Intellectual and
Scientific Professions
60
42.5 %
Unpaid domestic work
0
0 %
Senior officials of Public
Administration, Directors, and Senior
Managers of Companies
9
6.4 %
Military and militarized forces
1
0.7 %
5. Do you work in the maternal and child health area?
Yes
28
19.9 %
6,4 %
70,2%
23,4%
18-25 years 26-34 years 35-39 years
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DOI: 10.56732/pensarenf.v28i1.307
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No
113
80.1 %
6. Nationality
Portuguese
138
97.9 %
Other: Brazilian
2
1.4 %
Other: South African
1
0.7 %
7. Marital Status
Single
10
7.1 %
In a common-law marriage
56
39.7 %
Married
74
52.5 %
Divorced
0
0
Widowed
1
0.7 %
8. Family Type
Nuclear (couple with common
children)
116
82 %
Extended (couple, children, and
family relatives)
9
6.4 %
Blended (couple with children from
previous relationships)
11
7.8 %
Single parent (mother with children)
4
2.8 %
Single-person (consists of one person
living alone)
0
0 %
Other: Mother, daughter, and
grandmother
1
0.7 %
Most of the participants are primiparous; however, in 39
responses, other siblings of the baby were living in the same
house during the first weeks postpartum.
The majority of the participants experienced a dystocic
birth (54.6%), mostly cesarean (n=48). Sixty-four
participants had an eutocic birth (Table 2).
Table 2 – Data on pregnancy and childbirth referred to in the
questionnaire
Absolute
Frequency
Relative
Frequency
(%)
9.Number of siblings of the baby living in the same house during
the first 12 weeks postpartum
0
102
72.3 %
1
29
20.6 %
2
9
6.4 %
3
1
0.7 %
10. Current age of the baby/child
Less than 1 month
6
4.3 %
Between 1 and 3 months
22
15.6 %
Between 4 and 6 months
19
13.5 %
Between 7 months and 1 year
29
20.6 %
1 year
36
25.5 %
2 years
23
16.3 %
3 years
6
4.3 %
11. Did you take a course on childbirth and parenting
preparation?
Yes
89
63.1 %
No
52
36.9 %
I don't know what it is
0
0 %
12. Type of Birth
Eutocic (natural birth)
64
45.4 %
Vacuum (vaginal delivery using a
vacuum)
23
16.3 %
Forceps (vaginal delivery using
forceps)
6
4.3 %
Cesarean (birth through surgery)
48
34 %
13. Did you make a birth plan?
Yes
73
51.8 %
No
68
48.2 %
I don’t know what it is
0
0 %
14. Did you make a postpartum plan?
Yes
13
9.2 %
No
118
83.7 %
I don't know what it is
10
7.1 %
As for the ages of the babies/children, they range widely
from newborn to 3 years according to Graph 2.
Graph 2 - Distribution of the sample by current age of the baby/child
(n=141)
Most participants attended the birth and parenting
preparation program (63.1%); however, only 10.6% of the
participants completed the postpartum recovery course.
Additionally, while the birth plan was a concern for most
respondents (51.8%), only 9.2% of the participants created
a postpartum plan, and 71% reported being unaware of it
(Graph 3).
Graph 3 - Distribution of the sample concerning the realization of the
birth plan and postpartum plan (n=141)
The data regarding the postpartum period of the participa
nts are shown in Table 3.
Table 3 – Data on postpartum
Absolute
Frequency
Relative
Frequency
(%)
17. During which postpartum periods did you experience
difficulties?
First 2 hours (delivery room)
5
3.5 %
Hospitalization (postpartum ward)
21
14.9 %
Returning home after discharge from
the postpartum ward
26
18.4 %
Partner returning to work
19
13.5 %
Returning to work (if returned before
12 weeks postpartum)
3
2.1 %
Other: Isolation
1
0.7 %
Other: First weeks
1
0.7 %
Other: None
1
0.7 %
6
22
19
29
36
23
6
0
10
20
30
40
Less than
1 month
1-3
months
4-6
months
7-12
months
1 year 2 years 3 years
73
68
0
13
118
10
0
200
Yes No I don't know what it is
Birth Plan Postpartum Plan
66 | Pena, B.
Qualitative Original Article
Other: Period of adaptation to
breastfeeding
2
1.4 %
Other: First 2 to 3 weeks postpartum
2
1.4 %
Other: Time when left without support
1
0.7 %
No response to the question
59
41.8 %
20. Was the baby/child breastfed?
Yes
138
97.9 %
No
3
2.1 %
21. Was the decision to breastfeed or not made during
pregnancy?
Yes
133
94.3 %
No
8
5.7 %
23. Until what age was the baby exclusively breastfed (baby
ingested only breast milk)?
Less than 1 month
27
19.1 %
Up to 2 months
8
5.7 %
Up to 3 months
6
4.3 %
Up to 4 months
10
7 %
Up to 5 months
12
8.5 %
Up to 6 months
44
31.2 %
The baby is not yet 6 months old
and I am exclusively breastfeeding
34
24.1 %
24. When did you stop breastfeeding (exclusive breast milk or
not)?
Less than 1 month
10
7 %
Between 1 to 2 months
10
7 %
Between 3 to 4 months
11
7.8 %
Between 5 to 6 months
7
5 %
Between 7 months and 12 months
9
6.4 %
Between 12 months and 18 months
7
5 %
Between 19 months and 24 months
2
1.4 %
2 years
4
2.8 %
3 years
0
0 %
Other: Still breastfeeding
59
41.9 %
Other: Not applicable
3
2.1 %
25. Was the duration of breastfeeding as you had planned?
Yes
64
45.4 %
No, I breastfed longer than I had
planned
14
10 %
No, I breastfed for less time than I had
planned
40
28. 4 %
29. Did you take a postpartum recovery course?
Yes
15
10.6 %
No
126
89.4 %
30. Was self-care, such as eating, bathing, exercising, sleeping,
etc., a concern during this period?
Yes
99
70.2 %
No
42
29.8 %
33. Did you feel that there was a change in your relationship with
your partner?
Yes
104
73.8 %
No
37
26.2 %
36. If you used a contraceptive method postpartum, was it
chosen during pregnancy?
Yes
71
50.4 %
No
66
46.8 %
45. Were the aspects facilitating a positive postpartum
experience planned/prepared in advance?
Yes
70
49.6 %
No
71
50.4 %
Postpartum Difficulties:
Challenges in baby care were noted, specifically in “managing
the nights, colic (up to 4 months),” “traveling (baby hates car rides),”
Q11, “cutting nails and umbilical cord hygiene,” Q17, and “fear of
making mistakes,” Q54. Breastfeeding is identified as one of
the challenges; three participants did not breastfeed—one
by choice (Q128), one for maternal reasons (Q121), and
one due to difficulties in latching (Q126). Out of the
participants, 41.9% were still breastfeeding at the time of
filling out the questionnaire, 31.2% exclusively breastfed up
to 6 months, and 45.4% continued breastfeeding as
planned.
Some participants expressed difficulties in breastfeeding,
such as: “The baby had a short frenulum and we didn't know,”
Q16, “Difficulty in latching. This led to significant weight loss, sore
nipples, unbearable pain, beginning of mastitis, severe fatigue, and
difficulty managing emotions associated with this challenge,” Q39.
Self-care is a concern for the majority of participants
(70.2%), with physical and psychological recovery being
another challenge reported by the study participants,
notably: “vaginal pains,” Q1, “deprivation of sleep, intense
insomnia, anxiety, difficulty being confined with the baby, desire to
return to a routine, identity crisis, baby blues,” Q32, “great difficulty
in showering, going to the bathroom, walking, lifting, holding the baby,
sitting down. It was very difficult,” Q40, “emotional exhaustion and
doubt about what I was doing with my life,” Q68.
Marital relationship is impacted by difficulties in parental
roles, marital relationship, and sexuality. In the transition to
parenthood, it is mentioned how the relationship can
influence this transition and vice versa: “Different views on
motherhood,” Q25. Of the participants, 73.8% reported
changes in their relationship with their partner. Some
difficulties in marital and sexual relationships expressed are:
“Difficulty in communication and having time as a couple,” Q24,
“Mainly about the care of the baby and help with household chores.
The partner's work schedules made it difficult for him to be at home,
which led to distancing and a feeling of loneliness where everything
depended on me,” Q39, “There is no marital life, only parenthood,”
Q61, “Lack of sleep makes me more irritable, lack of time and
privacy for sexual activity,” Q80.
Regarding family planning, the majority chose the
contraceptive method during pregnancy (n=71), however,
one participant states that “At the health center, they only asked
me which contraceptive I wanted,” Q82.
The difficulties expressed by participants regarding the
support from health professionals and family or friends
within the support network include: “Overload when my
partner went to work,” Q4, “Lack of support in breastfeeding,” Q6,
“Social pressure to work,” Q16. Health professionals were
described as “uninformed, inconvenient, and persistent in their
opinion,” Q17, “providing contradictory information,” Q24,
“During COVID, I expected my family to be more present, but that
was an illusion,” Q56, “People help with the baby on the easy parts
but not with the more difficult tasks (household chores, cooking, etc.),”
Q80, “I did not even have consultations at the national health
service,” Q86.
Managing daily life presents another challenge, specifically
the management: “Lack of time/opportunity to do household
chores,” Q42, “Dealing with the older one,” Q57. Managing visits
was challenging: “Difficulty in setting limits during visits, the
timing of visits, contact with the baby, and dealing with unsolicited,
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judgmental opinions,” Q82. Returning to work was also
problematic due to “the absence of paternity leave because he is a
service provider and maternity leave being ridiculously short,” Q37,
“Lack of sleep drains energy needed for managing work-family-home
time,” Q49, “Balancing work schedules with daycare,” Q126, and
“Ability to replan professional future,” Q135.
Needs of the Triad from the Participants' Perspective
The identified needs of the triad include informational
needs such as “care that the mother should have with herself in
terms of nutrition, supplementation, and body care in the postpartum
period,” Q33, and “information about what are warning signs in the
baby, what can happen, what is normal or not,” Q40. Physical and
biological needs were expressed as “finding time for myself to
do sports, to take care of myself,” Q59, and “need for constant
hygiene,” Q70. Psychological and emotional needs were
noted for both the baby, as in “her need to always be in my lap
or with me close to her,” Q66, and for the mother/couple: “need
for emotional support,” Q16.
Social needs included “help with chores and baby care,” Q2,
“psychological support,” Q8, “holding the baby for a few moments,
making food,” Q20. One participant noted, “some [support]
would already be good. For 99% of the design of the follow-up by
health professionals in the system, the fourth trimester does not exist,”
Q34. Additional needs mentioned were “home visits in the
postpartum period for conducting the heel prick test to assess maternal
and newborn well-being,” Q52, and “Household chores, laundry
treatment, meals, and activities of the siblings,” Q61.
The Strengths that Contributed to a Positive Fourth
Trimester Experience
The strengths that emerged from this study, contributing
to a positive fourth trimester experience, include
experiences, cognitive strengths, biological and
intrapersonal strengths, psychological strengths, relational
and affective strengths, social and interpersonal strengths,
creating a plan, collaborative partnerships, and promoting
a protective environment.
Experiences as described include: “Having had a natural,
humanized, and respected childbirth. Being the second experience,”
Q15; “The childbirth experience was positive, very supported by the
nursing team, with no unnecessary instruments or cuts. It made my
recovery much quicker and lighter,” Q44. Cognitive strengths
were highlighted as “Many videos on the internet plus support from
the nurse,” Q26; “...seeking information in books written by nurses
and/or doctors,” Q104.
Biological and intrapersonal strengths expressed included
comments like “I think I had an excellent recovery because I did
not have significant sequelae from childbirth,” Q2, and “The baby
being calm,” Q5. Psychological strengths were highlighted
through reflections such as “simply looking in the mirror,” Q5;
“Mindfulness and recognizing that I cannot control everything,” Q41;
“Trusting myself, my partner, and my baby,” Q53; and “Breathing
deeply and always acting calmly and asking for help whenever I need
it,” Q76.
Relational and affective strengths like “Dialogue,” Q2;
“Babywearing,” Q12; “A lot of cuddling,” Q31; and “We did
everything together with a lot of respect for the process I was going
through and a lot of understanding about each other's roles. He took
care of me so that the postpartum process was more serene,” Q53,
were vital. Social and interpersonal strengths were evident
as participants mentioned, “I put him in daycare before returning
to work so I could sleep while he was there,” Q12; “Family support
and medical help,” Q8; “Sharing groups on social networks,” Q10;
and “Postpartum home visit,” Q25.
Further strengths included “Support consultations for
breastfeeding, speech therapy, and physiotherapy,” Q44; “Good
medical team, good nurses,” Q60; and “Shared parental leave with
the father,” Q62. Plans were created such as “Once a week we
go out just the two of us,” Q4; “Try to talk a little at night 2x/week,”
Q11; and “Having specific appointments and routines,” Q77.
Collaborative partnerships were described as “Support from
the baby's father,” “I could only manage when the father came home,”
Q3; “Dividing tasks at home, for example, while I was breastfeeding,
father made the meals,” Q25; and “Delegating tasks to the father,”
Q82. Additionally, promoting a protective environment
was crucial, including practices like “Rooming-in,” Q62; “The
father being with me and us being alone in the room,” Q66; and
“Leaving the hospital as soon as possible. A 36-hour hospital stay,”
Q89.
Table 4 - Categories and subcategories
Categories
Subcategories
Postpartum Difficulties
Baby Care
Breastfeeding
Physical and Psychological Recovery
Transition to Parenthood
Marital Relationship
Family Planning
Support Network
Daily Life Management
Needs of the Triad from the Participants'
Perspective
Informational
Physical and Biological
Psychological and Emotional
Social
The Strengths that Contributed to a
Positive Fourth Trimester Experience
Experiences
Cognitive Strengths
Biological and Intrapersonal Strengths
Psychological Strengths
68 | Pena, B.
Qualitative Original Article
Relational and Affective Strengths
Social and Interpersonal Strengths
Creation of a Plan
Collaborative Partnership
Promotion of a Protective Environment
Items for Elaborating the Postpartum Plan
The items for elaborating the postpartum plan were
obtained through five closed questions from Section IV of
the questionnaire (Table 5), with an option for a free text
response, and from open questions, specifically questions
number 15, 16, and 53.
Table 5 – Postpartum plan
Absolute
Frequency
Relative
Frequency
(%)
46. What options did you define or consider important to reflect
on/define during pregnancy?
The option to breastfeed or not
108
76.6 %
Type of contraception intended for
postpartum
49
34.8 %
Contacts of family and friends who
can support postpartum
105
74.5 %
Mother groups (online, in-person)
54
38.3 %
Contacts of health professionals
(Hospital, Health Centers, others)
102
72.3 %
First contact with health
professionals (who, how)
71
50.4 %
Who to contact for breastfeeding
support
121
85.9 %
Who to contact if experiencing
feelings of sadness
101
71.6 %
Postpartum recovery course
68
47.6 %
Other: Information
2
48.2 %
Other: Doula
1
0.7 %
Other: Logistics preparation of meals
and household tasks
1
0.7 %
Other: Follow-up of mothers with
pre-existing conditions that may
complicate postpartum
1
0.7 %
Other: Pelvic physiotherapy
1
0.7 %
47. In the first 2 hours (delivery room), is it important for the
mother/father to define in their plan:
Presence of the father or another
significant person
133
94.3 %
Skin-to-skin contact with the baby
from birth (by mother, father, or
another)
137
97.2 %
Breastfeeding in the first hour of life
128
90.8 %
Other: Delay non-urgent procedures
3
2.1 %
Other: Consent for the
administration of medication
1
0.7 %
Other: Not dressing the baby to
make skin-to-skin contact
1
0.7 %
Other: Privacy
1
0.7 %
Other: Information
1
0.7 %
Other: Immediate support in
breastfeeding
1
0.7 %
48. During hospitalization (postpartum ward), is it important
for the mother/father to define in their plan:
Presence of the father or another
significant person
139
98.6 %
Support in breastfeeding (how, who,
when)
129
91.5 %
Protective options for breastfeeding
(not introducing pacifiers, how
formula milk or breast milk is offered
if needed)
101
71. 6 %
First bath of the baby (who, when)
106
75.2 %
Presence during all procedures on
the baby
114
80.9 %
Prior information to parents about all
interventions on the baby
(medication, treatments)
129
91.5 %
Visits (who, when)
104
73.8 %
Other: Privacy
1
0.7 %
Other: options in deviations from
normality
3
2.1 %
Other: frequent skin-to-skin contact
1
0.7 %
49. Upon returning home, is it important for the mother/father
to define in their plan:
Organized baby clothes for the first
days
87
61.7 %
Where the baby will sleep
98
69.5 %
Baby care (who, how)
110
78 %
Other children (care, interaction with
the baby)
82
58.2 %
The first meals
81
57.4 %
Household tasks (who, how, when)
117
83 %
Visits (who, how, where, when)
122
86.5 %
Financial management (who and how
bills are paid)
55
39 %
Care of pets (who, what)
64
45.4 %
Time for the couple (how, when,
support network)
93
66 %
Time for self-care (what, who
supports, when)
118
83.7%
Other: Car safety
1
0.7 %
Other: Family outings
1
0.7 %
50. Upon returning to work, is it important for the
mother/father to define in their plan:
Who will take care of the baby
132
93.6 %
Baby's feeding/breastfeeding (how,
who, where)
126
89.4 %
Work conditions (schedules, what,
from when)
129
91.5 %
Reorganization of household tasks
(who, what, when)
114
80.9 %
51. In your opinion, should the postpartum plan be developed
only by the mother or the pregnant woman?
Yes
3
2.1 %
No
138
97.9 %
52. If not, indicate with whom the postpartum plan should be
developed?
With partner
138
97.9 %
With a family member
14
9.9 %
With a friend
5
3.5 %
With a maternal and obstetric health
nurse
55
39 %
Other: Doctor overseeing the
pregnancy
1
0.7 %
Other: Doula
3
2.1 %
Other: Information discussed with
the EESMO nurse beforehand
1
0.7 %
Other: In conjunction with the
support network
1
0.7 %
Pensar Enfermagem / v.28 n.01 / June 2024 | 69
DOI: 10.56732/pensarenf.v28i1.307
Qualitative Original Article
From the study, eleven items emerged for elaborating the
postpartum plan: information, baby care, baby feeding
plan/breastfeeding plan, recovery plan, family planning,
marital relationship, support network, management of daily
life, management of expectations, management of
deviations from normality/complications, and planning
and implementation (Table 6).
Table 6 – Items for elaborating the postpartum plan
Postpartum Plan Items
Quantitative
Data
Qualitative
Data
Information
x
x
Baby Care
x
x
Baby Feeding
Plan/Breastfeeding Plan
x
x
Recovery Plan
x
x
Family Planning
x
x
Marital Relationship
x
x
Support Network
x
x
Daily Life Management
x
x
Expectations Management
x
Management of Deviations
from Normality/Complications
x
Planning and Implementation
x
Information is necessary to create the postpartum plan as
expressed by the participants: “To have validated information on
various areas of child health to manage daily life, especially important
is the information on breastfeeding!” Q83, and “Demystify that the
woman does not have to bear everything alone and that she does not
have to be a superwoman at all” Q95.
Regarding baby care, needs include: “Stock of reusable diapers.
Management of baby's wake and sleep times” Q16, “Postponing non-
urgent procedures” Q20, “Baby care (e.g., not being separated, not
bathing)” Q37, “...administration or not of medication and vaccines”
Q66, and “Pregnant woman's and baby's bag, baby's bed and clothes
(...) Car safety” Q74.
For the feeding plan, needs are described as: “Management of
tandem breastfeeding” Q15, “Breastfeeding consultation” Q25, “...I
separated breastfeeding-friendly clothes” Q38, “Breastfeeding
accessories...” Q80, and “Immediate support in breastfeeding”
Q128.
Participants highlighted the importance of defining specific
elements of the recovery plan: “Frozen food, frozen perineal
pads” Q20, “nutritional and exercise plan for the mother” Q45,
“Comfortable, practical, and beautiful clothes for me (...) Importance
of postpartum gymnastics not only for physical rehabilitation but also
for emotional and social reintegration” Q79, “Recognizing warning
signs of postpartum depression (...) Time for myself. When to start
exercising” Q83.
Only 34.7% of the participants considered it important to
define the type of contraception intended for the
postpartum period during pregnancy. However, one
participant noted, “Think carefully about postpartum contraceptive
methods. The general choice is the pill and it may not be suitable, but
we might not be in the right state of mind at that time to say no.”
Q64.
Regarding marital relations, the participants emphasized:
“Very important in supporting the partner” Q19, “Family outings”
Q81, and “Organizing timings with the father” Q86.
A participant in the following way expressed the
importance of planning the support network:
“Everything. (...)
Home
: - for four months, family brought
food to freeze on weekends - an online shopping list to just
click 'come' - twice a week friends brought soup -
housekeeping help biweekly - teaching boyfriend how to do
laundry...
Visits
: - extended family was informed
throughout the pregnancy that we did not want visits unless
we invited them first - this was respected. - immediate family
(our parents) had to give us 24 hours alone with the baby at
home (...)
Education of the support network
: -
throughout the pregnancy, well before it, our options for the
baby and how we wanted to guide her were exposed and
discussed - ESSENTIAL (...).
Specialized support
:
- support by (…).
Network of mothers with babies
of the same age - MY GOD ABSOLUTELY
ESSENTIAL” Q19
Regarding the management of daily life, the majority of
participants considered it important to “leave as many things
done as possible” Q36, “restrict visits to just the grandparents, I made
food before childbirth and froze it…” Q44.
The participants considered it important to add the
management of expectations: “...adjusted expectations made the
most difference.” Q19, “Have a plan, but be open to the fact that
things may not all go as we want” Q42, and “to be discussed with
the person, not the importance of making decisions that may later prove
to be unrealistic, but to reflect on each topic” Q37; the management
of deviations from normality as:: “What to do in extraordinary
situations like intensive care/neonatology.” Q62, “Make a plan for
if something goes beyond what we expect, what to do if something goes
wrong” Q64, “What happens to the baby if something happens to the
mother” Q75; and the planning and implementation:
“...daily/hourly scheduling.” Q45, “The postpartum plan should be
part of the birth preparation course” Q71, and “It can be done online
or at a distance, since it might not be appealing or possible to leave the
house” Q93.
The quantitative data are detailed in Table 1.
Most (98%) considered that the postpartum plan should be
made with the partner (n=138), followed by 39% with a
nurse specialist in maternal and obstetric health, adding that
“During pregnancy to have a consultation where the postpartum is
discussed and not just about childbirth (childbirth passes quickly, the
postpartum does not)” Q22.
Discussion
This study revealed the difficulties in the postpartum
period, the needs of the triad from a maternal perspective,
the strengths that contributed to a positive experience in
the fourth trimester, and the items for elaborating the
postpartum plan. Concerning challenges in baby care, the
results corroborate the study by Alves et al.
20
, which states
70 | Pena, B.
Qualitative Original Article
that postpartum women are afraid of bathing, caring for the
umbilical cord, and soothing the child properly. Many of
the difficulties in breastfeeding stem from a lack of support,
insufficient information, pain, and negative emotions.
21,22
Research findings from Zivoder et al.
23
show that
difficulties and psychological disorders in the postpartum
period are common, affecting almost 50% of women
(44.46%), with Baby Blues being the most prevalent,
followed by postpartum depression and anxiety disorders.
The study notes that age and type of birth do not influence
the emergence of changes, whereas social factors such as
family support have a significant impact. The difficulties in
marital relationships expressed by the participants align
with the study by Asadi et al.
24
, which observes that
relationships with partners evolve into a new form of
cooperation for child care during this period. The
challenges of managing daily life are supported by the
studies of Ayers et al.,
25
Brown and Shenker,
26
Caetano et
al.,
27
Hadjigeorgiou et al.,
28
Joy et al.,
29
and Sakalidis et al.
30
This study corroborates the results of the scoping review
regarding maternal difficulties and concerns in the fourth
trimester, except for the added difficulties related to
multiculturalism, since the sample is predominantly
Portuguese. The needs of the triad identified from the
participants' perspective are supported by the study of
Ribeiro et al.,
6
which concludes that there is a need for
social, physical, emotional, and informational support in
the postpartum period. McLeish et al.
31
also emphasize the
necessity of emotional, informational, and practical support
during this time. These authors argue that gentle,
respectful, and empathetic interactions contribute to
feelings of security and appreciation.
The strengths that contributed to a positive experience in
the fourth trimester identified in this study include
experiences, cognitive strengths, biological and
intrapersonal strengths, psychological strengths, relational
and affectionate strengths, social and interpersonal
strengths, the creation of a plan, collaborative partnership,
and the promotion of a protective environment.
Information about breastfeeding typically comes from
contact with health professionals during monitoring visits,
courses, available literature, previous personal experiences,
or those of relatives and friends, with mothers often being
one of the largest sources of knowledge and direct support,
as mentioned by Oliveira et al.
32
Greater partner support in
the postpartum period is associated with higher self-
efficacy in breastfeeding, less depression, and less body
dissatisfaction.
19,33
Acquiring new skills and abilities promotes the
development of strengths, an opportunity created by
transitions according to Gottlieb.
13
Additionally, the
author
13
notes that the processes of body repair include
strengthening the immune system, improving cardiac and
renal function, and enhancing mind functionality, thereby
addressing emotional, mental, and spiritual states.
Restoring the whole involves acts of self-healing, such as
balancing and resting activities, promoting sleep, exercise,
eating well, promoting relaxation, and reducing stress.
13
Besides being a moment of happiness, the fourth trimester
can present considerable challenges for the woman, the
couple, and the family, and it may also pose challenges at
work, in the community, and in health policy. The results
align with Hannon et al.,
12
who assert that health education
focuses on supporting informed decision-making processes
as a positive resource that alleviates concerns and
difficulties. This includes care centered on the family—not
just the baby—support in the postpartum period, and
flexibility in returning to work, with accessible and nearby
daycares.
It is important to highlight the items suggested for
elaborating the postpartum plan, which include
information, baby care, baby feeding/breastfeeding plan,
recovery plan, family planning, marital relationship,
support network, management of daily life, management of
expectations, management of deviations from
normality/complications, and planning and
implementation. As Ribeiro et al.
6
emphasize, preparing the
support network is crucial, especially for the immediate
postpartum period, as it involves experiencing rapid
changes in the body and routine that make the woman feel
the need for support to cope with pain, breastfeeding
difficulties, and newborn care, along with fatigue and the
fear of the responsibilities that come with motherhood.
The same author corroborates and highlights the
importance of a positive childbirth experience, as well as
changes in routines in the remote postpartum period.
It should be noted that Strengths-Based Care (SBC)
provides a sense of centrality and empowerment in women,
leading to more effective performance in their self-care,
breastfeeding, and health promotion for returning to their
routine, according to Silva et al.
34
Conclusion
The fourth trimester is a concept that places the woman
(newborn and couple) at the center of care within the
family. This period requires time for the woman to adapt
and to be supported by a network that offers practical
support tailored to her needs and preferences. The
challenges mentioned include baby care, breastfeeding,
physical and psychological recovery, the transition to
parenthood, marital relationships, family planning, the
support network, and managing daily life. From the
maternal perspective, the bio-psycho-social needs of the
triad in the first 12 weeks postpartum were identified, along
with the strategies of the postpartum woman/couple to
overcome perceived difficulties, which facilitated the
construction of items to be included in the
postpartum plan.
The postpartum plan is an innovative concept, as pregnant
women and couples often focus on developing the birth
plan, frequently overlooking or undervaluing the
Pensar Enfermagem / v.28 n.01 / June 2024 | 71
DOI: 10.56732/pensarenf.v28i1.307
Qualitative Original Article
postpartum plan. However, most participants considered
planning one of the strengths or strategies for a positive
experience in the fourth trimester. Further research studies
are suggested on the development of the postpartum plan
in specific situations such as prematurity, disability, and
involving the couple.
Study Limitations
The sample is predominantly Portuguese, which makes the
group homogeneous on one hand, but on the other hand
limits the understanding of perspectives on the postpartum
plan and fourth trimester from various ethnic and
cultural origins.
The online nature of the study limits the accessibility of
participation homogeneously.
We could not extend the study to the paternal perspective
by applying the questionnaire to the father/partner of the
postpartum woman to know their perspective and
suggestions, which would have been an added value.
Authors’ Contributions
BP: Conception and design of the study, data collection,
analysis and interpretation of data and writing of the
manuscript.
MS: Guidance in the conception and design of the study,
analysis and interpretation of the data and critical revision
of the manuscript.
Conflicts of Interest and Funding
No conflicts of interest were declared by the authors.
Acknowledgments
The authors would like to thank all the participants in this
study and the Nursing Research, Innovation and
Development Centre of Lisbon (CIDNUR), which
provided access to WebQDA - Qualitative Data Analysis
software.
Support / Funding Sources
The study was not funded.
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