AROMATHERAPY AND FIRST STAGE LABOR PAIN 1

Reducing First Stage Labor Pain Among Laboring Women Using Aromatherapy

Natalie C. Sorensen

College of Nursing, University of South Florida

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Abstract

Clinical Problem: Women can experience extreme labor pain. Properly managing this pain using

evidence-based techniques creates a more pleasant laboring experience and helps prevent

negative mental health outcomes after childbirth (Namazi et al., 2014).

Objective: The objective of this synthesis is to assess whether aromatherapy is an effective

evidence-based practice that should be incorporated into standard practice for reducing first stage

labor pain. To find randomized controlled trials (RCTs) addressing this topic, the databases

PubMed and CINAHL were searched using the following search terms: aromatherapy, pain,

labor, and non-pharmacological.

Results: Evidence suggests that aromatherapy is an effective non-pharmacological technique for

reducing first stage labor pain as there is a statistically significant difference in the severity of

first stage labor pain experienced by women receiving aromatherapy and women not receiving

aromatherapy. Post-intervention mean pain scores (Yazdkhasti et al., 2016) and pain scores at the

various phases of cervical dilation (Hamdamian et al., 2018; Namazi et al., 2014; Tanvisut et al.,

2018) were both found to be significantly lower in women receiving aromatherapy than in

women not receiving aromatherapy. Mean differences between pain scores at hospital admission

and first stage labor pain scores were also significantly lower in women receiving aromatherapy

than in women not receiving aromatherapy (Tanvisut et al., 2018).

Conclusion: The studies in this synthesis reported that aromatherapy using Rosa damascena,

lavender, citrus, jasmine, geranium rose, and citrus aurantium is effective for reducing first stage

labor pain. Studies using other essential oils as well as studies comparing different essential oils

are both needed so that healthcare professionals can provide the most effective labor pain

management via aromatherapy.

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Reducing First Stage Labor Pain Among Laboring Women Using Aromatherapy

Managing pain experienced by women during childbirth is extremely important as labor

pain can be associated with negative mental health outcomes for women after childbirth (Namazi

et al., 2014). Current practice for pain management in laboring women includes the use of

pharmacological and non-pharmacological methods (Jones et al., 2012). Non-pharmacological

pain management includes techniques such as water immersion, massage, and acupuncture

(Chaillet et al., 2014). A specific type of non-pharmacological pain management that is

supported as an effective technique to incorporate into standard practice for labor pain

management is aromatherapy. Therefore, aromatherapy may serve as an effective pain

management technique for laboring women in the first stage of labor. In laboring women, what is

the effect of using aromatherapy compared to not using aromatherapy on the severity of pain

experienced in the first stage of labor?

Literature Search

The databases utilized for this literature search were PubMed and CINAHL. Search terms

that were used include aromatherapy, pain, labor, and non-pharmacological. This literature

search was limited to RCTs with publication dates falling between 2011 and 2021.

Literature Review

To assess the effectiveness of aromatherapy as a non-pharmacological pain management

technique for reducing first stage labor pain in laboring women, four RCTs were identified and

analyzed. The first RCT was conducted by Hamdamian et al. (2018) with the purpose of

assessing how the use of aromatherapy with Rosa damascena affects pain and anxiety in

nulliparous women (women who have never had a baby before) in the first stage of labor. The

sample size was 116 nulliparous women. Participants were randomly assigned to a control group
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(n=58) and an intervention group (n=58), but six participants, three from the control group and

three from the intervention group, were excluded from the analysis. The control group received

0.8 mL of normal saline on a 10 cm x 10 cm cotton gauze pad that was attached to the

participants’ collars. The intervention group received 0.8 mL of Rosa damascena on a 10 cm x

10 cm cotton gauze pad that was attached to these participants’ collars. The gauze pads were

attached when participants reached 4 cm of dilation and left attached until childbirth. Pain was

assessed 10 minutes after inhalation of either the normal saline or Rosa damascena at 4-5 cm, 6-7

cm, and 8-10 cm of cervical dilation. The researchers used the 11-point Numerical Rating Scale

for these pain assessments. Anxiety was assessed 10 minutes after inhalation at 4-7 cm of

cervical dilation and 8-10 cm of cervical dilation using the Spielberger anxiety questionnaire.

Neither pain nor anxiety were assessed during uterine contractions. The results of the study

indicated that pain severity at each assessment was significantly lower in the intervention group

than in the control group (p<0.05). These results suggest that aromatherapy with Rosa

damascena is an effective non-pharmacological method to reduce pain in laboring women in the

first stage of labor. Strengths of this study include random assignment of participants to control

and intervention groups, rationale for participant attrition, assessments that were conducted long

enough to study the full effects of the intervention, analysis of participants in the groups to which

they were assigned, an appropriate control group, similar demographic and baseline variables

between participant groups, and instruments of measurement that are both valid and reliable.

Weaknesses of this study are that assignment of participants was not concealed from the

individuals enrolling participants, and the providers were not blind to participant assignment.

A similar RCT was conducted by Namazi et al. (2014) with the purpose of assessing how

the use of aromatherapy with citrus aurantium affects first stage labor pain in primiparous
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women (women having their first child). The sample size was 122 primiparous women.

Participants were randomly assigned to a control group (n=61) and an intervention group (n=61),

but 4 participants from the intervention group and 5 participants from the control group were

excluded from the analysis. The control group received 4 mL of normal saline on gauze squares

that were attached to the participants’ collars. The intervention group received 4 mL of a citrus

aurantium distilled water solution (8 mg oil to 100 mL distilled water) on gauze squares that

were attached to the participants’ collars. In each group, the intervention specific to that group

was repeated every 30 minutes. Pain was assessed post intervention at 3-4 cm, 5-7 cm, and 8-10

cm of cervical dilation. The researchers used the 11-point Numerical Rating Scale for these pain

assessments. The results of the study indicated that pain severity at each assessment was

significantly lower in the intervention group than in the control group (p<0.001). These results

suggest that aromatherapy with citrus aurantium is an effective non-pharmacological method to

reduce pain in laboring women in the first stage of labor. Strengths of this study include random

assignment of participants to control and intervention groups, rationale for participant attrition,

assessments that were conducted long enough to study the full effects of the intervention,

analysis of participants in the groups to which they were assigned, an appropriate control group,

similar demographic and baseline variables between participant groups, and an instrument of

measurement that is both valid and reliable. Weaknesses of this study are that the researchers did

not mention whether or not assignment of participants was concealed from the individuals

enrolling participants, nor did they mention whether or not the providers or participants were

blind to participant assignment.

The third RCT analyzed was conducted by Tanvisut et al. (2018) with the purpose of

assessing how the use of aromatherapy affects pain in labor. The sample size was 106 Thai
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primigravidae, or women that are pregnant for the first time. Participants were randomly

assigned to a control group (n=53) and an intervention group (n=53), but two participants were

excluded from the analysis, one from each group. The control group received standard obstetric

care, while the intervention group received standard obstetric care in addition to a continuous

essential oil diffusion with a ratio of 4 drops of essential oil to 300 mL of water. The essential oil

diffusion given to the intervention group was started on admission and completed at the end of

the first stage of labor. Participants in the intervention group used the essential oil of their choice

among citrus, geranium rose, lavender, and jasmine. Pain was assessed on admission and at the

latent (3-4 cm of cervical dilation), early active (5-7 cm of cervical dilation), and late active (8-

10 cm of cervical dilation) phases of labor using the 11-point Numeric Rating Scale. The authors

of this study reported that the median pain scores at the latent and early active phases were

significantly lower in the intervention group than the control group (p<0.001). The authors also

reported that the mean differences in pain scores between the pain scores on admission and the

pain scores at the latent and early active phases were significantly lower in the intervention

group than the control group (p=0.010 and p=0.031). These results indicate that aromatherapy

with citrus, geranium rose, lavender, or jasmine is an effective non-pharmacological method to

reduce pain in laboring women in the first stage of labor. Strengths of this study include random

assignment of participants to control and intervention groups, rationale for participant attrition,

assessments that were conducted long enough to study the full effects of the intervention,

analysis of participants in the groups to which they were assigned, an appropriate control group,

similar demographic and baseline variables between participant groups, and an instrument of

measurement that is both valid and reliable. Weaknesses of this study are that assignment of

participants was not concealed from the individuals enrolling participants, and neither the
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providers nor the participants were not blind to participant assignment. Participants were not

blind to their assignment because participants were given the option to choose one of four

essential oils to use for the aromatherapy intervention. Because this choice was given to

participants, it is worth noting that some participants’ pain could have been affected by a placebo

effect in addition to the effect of the aromatherapy. This is because some of the participants

might regularly use and like one of the oils that were offered, and therefore, they might have had

a preconceived notion that the oil would help reduce their pain. Additionally, the use of several

essential oils is a weakness of the study because one essential oil could have been more effective

than the others at reducing pain.

The fourth RCT was conducted by Yazdkhasti et al. (2016) with the purpose of assessing

how the use of lavender essence aromatherapy affects the severity of pain experienced in labor as

well as the duration of labor. The sample size was 120 nulliparous women who were randomly

assigned to a control group (n=60) and an intervention group (n=60). One participant from the

control group was excluded from the analysis. At 5-6 cm, 7-8 cm, and 9-10 cm of cervical

dilation, the control group received 2 drops of distilled water on their palm and was asked to rub

their hands together and smell the water for three minutes at a distance of 2.5-5 cm away from

their nose. The intervention group was asked to follow the same procedure, but instead of

receiving distilled water, the group received a 10% lavender essence, 90% distilled water

solution. A baseline pain assessment was obtained at 3-4 cm of cervical dilation in both groups.

Pain was then assessed at 5-6 cm, 7-8 cm, and 9-10 cm of cervical dilation both before and 30

minutes after a contraction in both groups. The authors used the Visual Analog Scale for their

pain assessments. The length of the active phase of labor as well as the second stage of labor

were also recorded. The results of the study showed that the intervention group’s post-
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intervention mean pain intensity score was significantly less than the control group’s post-

intervention mean pain intensity score (p=0.001). These results indicate that aromatherapy with

lavender essence is an effective non-pharmacological method to reduce pain in laboring women

in the first stage of labor. Strengths of this study include random assignment of participants to

control and intervention groups, rationale for participant attrition, assessments that were

conducted long enough to study the full effects of the intervention, analysis of participants in the

groups to which they were assigned, an appropriate control group, similar demographic and

baseline variables between participant groups, and an instrument of measurement that is both

valid and reliable. Weaknesses of this study are that assignment of participants was not

concealed from the individuals enrolling participants, and the providers were not blind to

participant assignment.

Synthesis

As described above, the studies conducted by Hamdamian et al. (2018), Namazi et al.

(2014), and Tanvisut et al. (2018) reported that laboring women receiving aromatherapy had

significantly lower pain scores at the various phases of cervical dilation than did laboring women

not receiving aromatherapy. Hamdamian et al. (2018) reported a significant difference in pain

scores between groups at 4-5 cm, 6-7 cm, and 8-10 cm of cervical dilation (p<0.05), while

Namazi et al. (2014) reported a significant difference at 3-4 cm, 5-7 cm, and 8-10 cm of cervical

dilation (p<0.001). Like Namazi et al. (2014), Tanvisut et al. (2018) also reported a significant

difference at 3-4 cm and 5-7 cm of cervical dilation (p<0.001). In addition, the study conducted

by Tanvisut et al. (2018) reported that the mean differences in pain scores between pain scores

taken on admission and pain scores taken at the latent and early active phases of labor were

significantly lower in the intervention group than the control group (p=0.010 and p=0.031). In
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the fourth and final study discussed in the previous section, Yazdkhasti et al. (2016) reported

significantly lower post-intervention mean pain scores in women who were receiving

aromatherapy than in women who were not receiving aromatherapy (p=0.001).

The results of these four studies indicate that aromatherapy with either Rosa damascena,

lavender, citrus, jasmine, geranium rose, or citrus aurantium is an evidence-based intervention

that can be used to reduce pain experienced by laboring women in the first stage of labor.

Although all of the studies did not use the same instruments of measurement, they all used

instruments that are both valid and reliable. Additionally, although the studies used different

ways to analyze their data (which included means, medians, and mean differences), all of the

studies’ data represented the difference in first stage labor pain experienced by women using

aromatherapy and women not using aromatherapy. All four studies had the same strengths and

similar weaknesses. The study conducted by Tanvisut et al. (2018), however, had a unique

weakness in the fact that multiple essential oils were provided to participants.

Clinical Recommendations

Considering the evidence presented in this synthesis, aromatherapy using either Rosa

damascena, lavender, citrus, jasmine, geranium rose, or citrus aurantium is a non-

pharmacological intervention that effectively reduces pain experienced by laboring women in the

first stage of labor. More research needs to be done to assess the effect of other essential oils on

first stage labor pain. Research that compares different essential oils’ effects on first stage labor

pain also needs to be done so that healthcare workers can be aware of which oils are the most

efficacious in reducing first stage labor pain.

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