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Clinical aromatherapy for pregnancy, labor and postpartum.

Introduction

Drawing on published research and clinical experience, clinical aromatherapy may be a potentially effective complementary practice in childbirth. This information will be useful for those who teach and care for the childbearing family. The aim is for clinical aromatherapy to become better understood as a potential tool for maternal health, thus making integration easier.

Smell is one of the first senses to develop in the womb. Research has shown that babies can identify their mothers from smells first experienced in the womb (Faas, Resino, & Moya, 2011; Schaal, Marlier, & Soussignan, 2000). Odor has a direct pathway to the limbic part of the brain, in particular to the amygdala that governs fear (Buckle, 2007). Familiar smells can be calming and soothing at stressful times (including childbirth), and some smells can have a profound psychological effect (Vermetten, Schmahl, Southwick, & Bremner, 2007). Most hospitals do not smell reassuring.

Aromatherapy is the use of essential oils, obtained from aromatic plants, for therapeutic properties (Buckle, 2014, in press). Clinical aromatherapy is recognized as part of holistic nursing by the American Holistic Nurses Association and by most State Boards of Nursing (Buckle, 2003). Clinical aromatherapy is also used by doctors, massage therapists,

nurse practitioners, occupational therapists, and many other healthcare workers (Cordell & Buckle, 2013).

Essential oils can have many beneficial properties relevant to pregnancy, labor, delivery, and postpartum (Walls, 2009). For example, inhaling peppermint, spearmint, lavender, and ginger can relieve nausea (Reagan, 2009). Lavender, frankincense, and rose were found to relieve anxiety in labor (Burns, Zobbi, Panzeri, Oskrochi, & Regalia, 2007). German chamomile (Matricaria recutita) and Immortelle (Helicrysum italicum) have strong anti-inflammatory and healing actions. When diluted and applied topically, these two essential oils could be added to lavender (Lavandula angustifolia)--already found useful to aid perineal healing (Vakilian, Atarha, Bekhradi, & Chaman, 2011).

Rose (Rosa damascena) and lavender (Lavandula angustifolia) relieved anxiety and depression in postpartum women (Conrad & Adams, 2012). Many essential oils, for example teatree (Melaleuca alternifolia), have antimicrobial properties, and these can reduce the possibility of Hospital Acquired Infections (HAIs) such as Methicillin Resistant Staphylococcus aureus (MRSA) or Acinetobacter baumannii (Duarte, Ferriera, Silva, & Dominigues, 2012; Warnke, Lott, Sherry, & Podschun, 2013).

Aromatherapy is widely recognized as being useful in stress (Varney & Buckle, 2013), and clearly, labor is a stressful time for most women. Therefore it is not surprising that current reports suggest aromatherapy can reduce stress in pregnancy and childbirth (Conrad, 2010; Tillet & Ames, 2010). This article is supported with information from hospitals in Fort Worth, TX, Ridgewood, NJ, and Marshall, TX who use aromatherapy in their L & D departments.

Published Evidence

Aromatherapy for laboring mothers was introduced into a British hospital in the early 1990s by midwives Burns and Blamey (1994). Burns and Blamey's initial six-month evaluation of aromatherapy on 500 laboring women in a maternity hospital in Oxford led the way to a much larger eight year study of 8,058 women (Burns, Blamey, Ersser, Barnetson, & Lloyd, 2000). The essential oils used were chamomile, clary sage, eucalyptus, frankincense, jasmine, lavender, lemon, mandarin, peppermint and rose (Burns et al., 2000). Women in labor were offered aromatherapy to relieve symptoms such as anxiety, pain, nausea, and vomiting or to help strengthen their contractions (Burns et al., 2000). Routine data were collected over eight years on the women who received aromatherapy and compared to the data on women who were not given aromatherapy (n = 15,799) (Burns et al., 2000). Outcome measures included mothers' ratings of effectiveness, outcomes of labor, use of pharmacologic pain relief, uptake of intravenous oxytocin, reported associated symptoms, and annual costs (Burns et al., 2000). More than 50% of mothers rated aromatherapy as helpful, and only 14% found it unhelpful (Burns et al., 2000). The use of aromatherapy was not confined to low-risk mothers 60% were primigravidae, and 32% had induced labor (Burns et al., 2000). Aromatherapy appeared to reduce the need for additional pain relief, and the use of pethidine declined from 6% to 0.2% of women during the study (Burns et al., 2000). Aromatherapy also appeared to enhance labor contractions in women in dysfunctional labor (Burns et al., 2000). A very low number of associated adverse symptoms were reported (1%) (Burns et al., 2000).

A further study Burns, Zobbi, Panzeri, Oskrochi, and Regalia (2007) carried out in an Italian maternity unit found significantly more babies born to control participants were transferred to NICU than in the aromatherapy group: 0 versus 6 (2%, p = 0.017) (Burns et al., 2007). Pain perception was also reduced in the aromatherapy group for first time mothers (Burns et al., 2007).

Today, aromatherapy is a popular care option for mothers and midwives in many countries for myriad symptoms, such as nausea in pregnancy (and labor), hemorrhoids, exhaustion, pain, sleeplessness, anxiety, postpartum mood disorder, and episiotomy healing (Adams, 2012; Dhany, 2008; Maddocks-Jennings & Wilkinson, 2004; Tillet & Ames, 2010).

A retrospective study by Dhany, Mitchell, and Foy (2012) explored if an aromatherapy and massage intrapartum service (AMIS) reduced the need for analgesia during labor. Seven essential oils were used: bergamot, clary sage, frankincense, lavender, jasmine, peppermint, and rose (Dhany et al., 2012). The essential oils were intended to target specific symptoms: symptoms requiring analgesia or antispasmodics; reduction of fear; mood elevating; calming; and enhancement of uterine action (Dhany et al., 2012). Some were also used to help to balance emotions, nausea, bereavement, and depression (Dhany et al., 2012). The analysis showed the AMIS had a positive impact and reduced the need for anesthesia during labor, thus contributing to improved maternal and neonatal outcomes (Dhany et al., 2012).

Nausea

There have been several published studies on aromatherapy for nausea. Most used peppermint (Hines, Steels, Change, & Gibbons, 2012; Reagan, King, & Clements, 2009), ginger (Boone & Shields, 2009; Ensiyeh & Sakineh, 2009), citrus peel (Stringer & Donald, 2011), or mixtures that included peppermint or ginger (de Pradier, 2006; Hunt, Dienemann, Norton, & Hartley, 2012). While most studies are on post-operative or chemo-induced nausea, studies have found inhaled essential oils useful for both early morning sickness and nausea in labor. However, an Iranian study found a "mint" essential oil (no botanical name given) floated in a bowl of water by the bed overnight did not reduce nausea the following morning (Pasha, Behmanesh, Mohsenzadeh, Hajahmadi, & Moghadamnia, 2010).

Analgesia

Maddocks-Jennings and Wilkinson (2004) found women who used a range of essential oils often required less analgesia. Kaviani, Azima, Alavi, and Tabaei (2014) found the effect of lavender reduced the perception of labor pain, and women's self-evaluation showed them to be more content. However, there were no differences in the duration of the first or second stages of labor, nor was there a significant difference regarding the ist and 5th minute Apgar score between the control and aromatherapy groups (Kaviani et al., 2014).

Episiotomy Healing

Vakilian et al. (2011) conducted a randomized control trial on 120 primiparous women with single pregnancy. The women in Vakilian et al.'s study had had normal spontaneous vaginal delivery and episiotomy and were not suffering from any acute or chronic disease or allergy. They were randomly allocated to the aromatherapy or control group (Vakilian et al., 2011). The aromatherapy group received lavender (Lavandula angustiolia) oil, and the controls received Povidoneiodine (Vakilian et al., 2011). Incision sites were assessed on the 10th day postpartum (Vakilian et al., 2011). Vakilian et al. reported 25 out of 60 women in the lavender group reported no pain, whereas 17 mothers in the control group had no pain (p = 0.06).

Comfort

Coleman Smith (2012) taught comfort methods using aromatherapy during childbirth classes to give the mother a sense of control during their labor. Coleman Smith suggested a foot soak of peppermint, a back massage with mandarin, rose, or ylang ylang, or a hand massage with eucalyptus. While aromatherapy can be of comfort in labor, having a doula who also has experience of using aromatherapy in labor can be very beneficial. Many cultures encourage women to have an experienced companion to encourage the mother and be pro-active in her comfort (Gruber, Cupito, & Dobson, 2013; Habanananda, 2004; Stevens, Dahlen, Peters, & Jackson, 2011).

Labor and Delivery

Rose (Rosa damascena) can be especially good in early labor when the woman may be more anxious. Rose can also help women sleep. Hongratanaworakit (2009) explored the effect of topically applied rose oil (Rosa damascena). When compared to placebo, rose oil reduced respiration rate, O2 saturation, and systolic blood pressure. Participants in the rose oil group rated themselves as more calm, more relaxed, and less alert than those in the control group (Hongratanaworakit, 2009).

Jasmine, frankincense, and peppermint with back massage or compression to the forehead have been shown to be effective in active and transition (Coleman Smith, 2012; Pollard, 2008; Horowitz, 2011). Clary sage (Salvia sclarea) is thought to increase uterine contractility as well as acting as a stress reducer and anti-depressant (Coleman Smith, 2012).

Postpartum Mood Disorder

Imura, Misao, and Ushijima (2006) conducted a controlled study (n = 26) to explore the use of aromatherapy massage on postpartum mood. The aromatherapy group received a mixture of neroli (Citrus aurantium flos) and lavender (Lavandula officinalis) in a massage on the second postpartum day, and the control group received standard medical care (Imura et al., 2006). Four standardized questionnaires were used before and after the intervention: Maternity Blues Scale, State-Trait Anxiety Inventory, Profile of Mood States, and Feeling Toward Baby Scale (Imura et al., 2006). In the aromatherapy group, post treatment scores significantly decreased for the Maternity Blues Scale (p = 0.01), the State-Anxiety Inventory (p = 0.001), and all but one of the Profile of Mood States subscales (Imura et al., 2006).

Infertility

Essential oils for infertility include ylang ylang, clary sage, geranium, fennel, anise, cypress, and rose. These oils decrease stress and anxiety and may aid in conception. Inhalation, topical application on the abdomen and low back, and massage may be beneficial (Tillett & Ames, 2010). Buckle has had some success regulating irregular periods that have contributed to infertility by using clary sage, geranium, and rose 10% applied to abdomen and back from the last day of period until ovulation.

Using Clinical Aromatherapy in a Hospital

Clinical aromatherapy was added to the RN's toolkit of comfort measures for labor and postpartum at St.Vincent Women's Hospital in Indianapolis, Indiana, five years ago. Today, every bedside RN has completed training (under direction of Kathy Ryan, RN CCAP) that enables them to offer six essential oils for inhalation only. A clinical aromatherapy policy was created to provide guidelines for the safe administration of essential oils in a clinical setting as a nursing intervention. This meant a physician order was not required to use aromatherapy. After seeing the benefits of clinical aromatherapy in action, the physicians became very supportive of offering aromatherapy.

Patients are educated about the use of essential oils during childbirth preparation classes and during their pre-admission Monogram Maternity appointment, where a birth plan is created. Fliers describing each oil and instructions for their use at home, are shared. Essential oils kits and resource materials are kept in each unit's secured Medicine room. In order to address safety and infection control concerns, preparations for individual patient use are made up in the medicine room and then brought directly to the patient's room in a labeled medicine cup.

Medical history and allergies are reviewed before administering any essential oil. One to two drops are placed on a gauze square in a medicine cup, and safety precautions are emphasized with the patient before giving them the medicine cup. Patient are instructed to close their eyes and take a long slow inhalation through their nose, repeating as needed.

Nurses are trained to understand the contraindications and precautions of essential oils in this patient population. Patients are told not to apply undiluted essential oils directly to their skin; to only use them externally, avoiding the eyes; and to keep the medicine cup out of the reach of children. As an extra precaution, patients are advised to avoid inhaling essential oils during the first trimester of pregnancy, and nurses are told to observe this safety concern.

Essential Oil Choices for Patients

Essential oils offered (by inhalation only) are:

* Lavender (Lavandula angustifoliaa) for relaxation and sleep

* Bergamot (Citrus bergamiaa) for an uplifting and refreshing way to reduce stress

* Ginger (Zingiber officinalis) to relieve nausea

* Mandarin (Citrus reticulata) for a gentle, calming effect

* Peppermint (Mentha pipertia) for nausea, headaches, fatigue and inability to void

* Tea Tree (Melaleuca alternifolia) to relieve a stuffy nose and congestion.

Patients are encouraged to use essential oils simultaneously with the Skylight guided imagery programs available through the hospital TV system. Lavender, mandarin, and peppermint are the essential oils most frequently chosen, and patients report success in relieving discomfort and decreasing their stress.

Peppermint and ginger are available for use immediately after a cesarean section to relieve nausea and to lessen the potential use of antiemetic medications. The hospital has found that inhaling 1-2 drops of peppermint, ginger, or a blend of mandarin, peppermint, and ginger can relieve the discomfort of nausea during labor.

Postpartum RNs frequently suggest the use of peppermint when a patient is unable to void. A drop of peppermint is placed on a tissue in the urine collection container while the patient holds the medicine cup under their nose, taking slow deep breaths of peppermint. With peppermint's smooth muscle relaxation qualities, RNs report that it can be a successful strategy and is their first choice in this situation. This is interesting as a few drops of spirit of peppermint were placed in the urinary bottle if a male patient had problems urinating, over forty years ago!

RNs with advanced training in the safety and mixing of specific oils in small dilutions (often as low as i%) have created favorite blends for use in Labor and Postpartum. These blends can be used in a massage lotion or oil, a soothing foot-bath, or drops in the shower for a refreshing scented steam. The ones most useful include:

* Clary Sage, Roman Chamomile, and Lavender--While it has not been observed to be effective to initiate contractions, the nurses believe this blend may assist to increase the strength of existing contractions. Contraindications include a patient with a uterine scar, hyper stimulated contractions, or in conjunction with Pitocin or any other medication used to enhance labor. This is one blend that is discussed with the patient's physician before use. Documentation of physician's approval is placed in nursing notes for the use of Clary Sage during labor.

* Lavender and peppermint blended with fractionated coconut oil and Epsom salts are added to warm water in a basin for a refreshing foot-bath. Care partners are encouraged to massage the patient's feet at the same time.

* A 'Peace' blend containing Bergamot, Lavender and Mandarin in fractionated coconut oil can be calming, yet uplifting, during a long labor.

* For those experiencing grief after a loss or an unexpected outcome, spritzers containing various combinations of Frankincense, Jasmine, Lavender, and Rose in a spray bottle of water are offered. This can be comforting while the patient is in the hospital, and their own spray is given to them for use after discharge.

* Lavender and Roman Chamomile are mixed with a lotion and given to the Care Partners to use as a comforting rub during Labor. One patient wrote to thank her nurse stating: "The delivery made for a long day but the scent of lavender and chamomile helped me relax and make it through! My mom and husband rubbed my back and neck to help take my mind off things and to help with the aches and pains of delivery! I use a little of the lotion now every night--it reminds me of the beautiful night my baby was born--scent is so tied to memory!"

It is a privilege to be present when a baby is born. The goal of everyone present is to create a calm healing environment so mothers can have a best possible birth experience. Integrating clinical aromatherapy into maternal health care can enhance the experience and improve the comfort of laboring mothers, thus allowing them to focus on their goals for labor, for their baby, and for their immediate future together.

The Importance of Training

Essential oils are highly concentrated and some are contra-indicated in pregnancy and in labor (Tisserand & Young, 2013). It is strongly advised that those wanting to use aromatherapy in pre- and postpartum care learn how to use essential oils clinically. Training can be done easily by undertaking a clinical training that is specifically created for pregnancy and labor. This will enable the user to feel confident and comfortable about advising mothers what to use and what to avoid.

Take Home Message

Incorporating clinical aromatherapy into a childbirth care program enhances the comfort of laboring mothers and allows them to focus on their goals for labor--to produce a healthy, beautiful baby. However, essential oils are complex, concentrated extracts, and training is strongly recommended.

References

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Boone, S., & Sheilds, K. (2005). Treatment of pregnancy-related nausea and vomiting with ginger. Annals of Pharmacotherapy, 39, 1710-1713.

Buckle, J. (2003). Clinical aromatherapy: Essential oils in practice (2nd ed.). London, England: Churchill Livingstone.

Buckle, J. (2007). Literature review: should nursing take aromatherapy more seriously? British Journal of Nursing, 16(2), 116-120.

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Burns, E, & Blamey, C. (1994). Using aromatherapy in childbirth. Nursing Times, 90(9), 54-60.

Burns, E. E., Blamey, C., Ersser, S. J., Barnetson, L., & Lloyd, A. J. (2000). An investigation into the use of aromatherapy in intrapartum midwifery practice. Journal of Alternative and Complementary Medicine, 6(2),141-147.

Burns, E., Zobbi, V., Panzeri, D., Oskrochi, R., & Regalia, A. (2007). Aromatherapy in childbirth: A pilot randomized controlled trial. BJOG An International Journal of Obstetrics and Gynaecology, 114, 838-844.

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Conrad, P., & Adams, C. (2012). The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman--A pilot study. Complementary Therapies in Clinical Practice, 18(3), 164-168.

Cordell, B., & Buckle, J. (2013). The effects of aromatherapy on nicotine craving on a U.S. campus: A small comparison study. Journal of Alternative and Complementary Medicine, 19(8), 709-713.

de Pradier, E. (2006). A trial of a mixture of three essential oils in the treatment of postoperative nausea and vomiting. International Journal of Aromatherapy, 16(1), 15-20.

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Duarte, M., Ferriera, S., Silva, F., & Dominigues, F. (2012). Synergistic effect of coriander oil and conventional antibiotics against Acitenobacter baumannii. Phytomedicine, 19(3), 236-238.

Ensiyeh, J., & Sakineh, M. (2009). Comparing ginger and vitamin B6 for the treatment of nausea and vomiting in pregnancy: A randomized, controlled trial. Midwifery, 25(6), 649-653.

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Kaviani, M., Azima, S., Alavi, N., & Tabaei, M. H. (2014). The effect of lavender aromatherapy on pain perception and intrapartum outcome in primiparous women. British Journal of Midwifery, 22, 125-128.

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Stevens, J., Dahlen, H., Peters, K., & Jackson, D. (2013). Midwives' and doulas' perspectives of the role of the doula in Australia: A qualitative study. Midwifery, 27(4), 509-516.

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Vakilian, K., Atarha, M., Bekhradi. R., & Chaman, R. (2011). Healing advantages of lavender essential oil during episiotomy recovery: a clinical trial. Complementary Therapies in Clinical Practice, 17(i), 50-53

Varney, E., & Buckle, J. (2013). Effect of inhaled essential oils on mental exhaustion and moderate burnout: A small pilot study. Journal of Alternative and Complementary Medicine, 19(i), 69-7L

Vermetten, E., Schmahl, C., Southwick, S., & Bremner, J. (2007). Positron tomographic emission study of olfactory induced emotional recall in veterans with and without combat-related stress disorder. Psychopharmacology Bulletin, 40(i), 8-30.

Walls, D. (2009). Herbs and natural therapies for pregnancy, birth and breastfeeding. International Journal of Childbirth Education, 24, 29-37.

Warnke, P., Lott, A., Sherry, E., & Podschun, R. (2013). The ongoing battle against multi-resistant strains: in vitro inhibition of hospital-acquired MRSA, VRE, Pseudomonas, ESBL, E coli and Klebsiella species in the presence of plant derived antiseptic oils. Journal of Cranio-Maxillofacial Surgery, 41(4), 321-326.

Dr. Jane Buckle is the Director RJ Buckle Associates LLC www. rjbuckle.com and the author of Clinical Aromatherapy in Nursing (1997), Clinical Aromatherapy in Practice (2003) and Clinical Aromatherapy in Healthcare (due early 2015). In 1996, she created the first clinical aromatherapy program (CCAP) in USA. It was the first aromatherapy program to be endorsed by a national organization (The American Holistic Nurses Association) in 1999. She has trained over 3,000 nurses and doctors and now lives in London.

Kathy Ryan, is the Clinical Coordinator of the Monogram Maternity Program at St. Vincent Women's Hospital, Indianapolis, IN. Kathy has 37years of experience in Maternal Child Nursing. Certificated in the 'M' technique and as a CCAP (Certified Clinical Aromatherapy Professional), Kathy was instrumental in creating The St. Vincent Integrative Health Team.

Karen B. Chin, RN, MS, CCAP is Adjunct Faculty, ADN Program at Panola College, in Panola St, Carthage, Texas. Karen's ground-breaking, investigational study on the use of teatree (Melaleuca alternifolia in wound-healing was published in the Journal of Alternative & Complementary Medicine in 2013. She works a staff RN in PACU at the Good Shepherd Medical Center in Marshall, Texas.
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Author:Buckle, Jane; Ryan, Kathy; Chin, Karen B.
Publication:International Journal of Childbirth Education
Article Type:Report
Date:Oct 1, 2014
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