Aromatherapy in Obstetrics: A Critical Review of the Literature
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CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 00, Number 00, 000–000
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Aromatherapy in
Obstetrics: A Critical
Review of the
Literature
ANNA C. BERTONE, MPH,
and REBECCA L. DEKKER, PhD, RN
Evidence Based Birth, Lexington, Kentucky
Abstract: Aromatherapy is the use of highly concen- aromatic essential oils from plants have
trated aromatic plant oils administered in various been used as perfumes and medicines for
ways for a wide range of therapeutic indications.
The purpose of this review is to present an overview over 3500 years. René-Maurice Gattefossé,
of the evidence on aromatherapy during the perinatal a French chemist and perfumer, coined the
period. There is research on the prenatal use of term, perhaps to distinguish between essen-
aromatherapy to treat nausea and vomiting, reduce tial oils used in perfumery versus those used
stress, and support immune function; the intrapartum medicinally to enhance physical and mental
use of aromatherapy for labor pain/anxiety and labor
progress; and the postpartum use of aromatherapy for wellbeing.1 Unlike herbal medicine, which
postcesarean symptoms, perineal trauma, sleep, and uses whole plants to achieve a therapeutic
symptoms of depression and anxiety. Overall, the effect, essential oils used in aromatherapy
evidence suggests that aromatherapy can be adminis- are highly concentrated extracts derived
tered safely and effectively in obstetrics. from plant roots, leaves, bark, seeds, and
Key words: aromatherapy, essential oils, complemen-
tary medicine, parturition, prenatal, labor pain flowers.2 It can take many pounds/kilo-
grams of plant material to produce one
The term “aromatherapie” first came into bottle of essential oil. The concentrated
use in the early 20th century, although chemicals in the oils give them different
properties (ie, relaxing, stimulating, pain-
Correspondence: Rebecca L. Dekker, PhD, RN, Evi- relieving) that can be harnessed for a
dence Based Birth, PO Box 4962, Lexington, KY. beneficial effect.
E-mail: info@evidencebasedbirth.com
Aromatherapy may help with pain
Supplemental Digital Content is available for this management by activating thought and
article. Direct URL citations appear in the printed text
and are provided in the HTML and PDF versions of mental processes that interrupt the trans-
this article on the journal’s website, www.clinicalobgyn. mission of pain signals, taking attention
com. away from a painful sensation, stimulat-
A.C.B. is a research consultant with Evidence Based ing the release of endorphins, and helping
Birth. R.L.D. is the founder and CEO of Evidence
Based Birth headquartered in Lexington, KY. to reframe thoughts about uncomfortable
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 00 / NUMBER 00 / ’’ 2021
www.clinicalobgyn.com | 1
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sensations. The theory behind this over- CAM therapies, such as aromatherapy,
arching pain management modality is deserve attention in obstetrics because
known as “Control of the higher centers they have become increasingly popular
of the central nervous system,” or CNSc.3 over recent decades. Studies report prev-
Other pain relief strategies within the alence rates of CAM use in pregnancy
CNSc theoretical model include medita- ranging between 1% and 87%, with most
tion, yoga, hypnotherapy, continuous estimates ranging between 20% and 60%.6
support, breathing/relaxation techniques, Some of this use is self-prescribed, and
and music. In addition to the CNSc some is due to health care providers
mechanism, aromatherapy may also work prescribing or offering advice on CAM
by reducing cortisol and increasing sero- therapies. A survey of 135 health care
tonin levels.4 providers (midwives, obstetricians, anes-
Researchers have theorized that aroma- thetists) in Northeast Scotland found that
therapy exposes people to scent molecules a third of respondents had recommended
that attach to olfactory receptors in the the use of CAM therapy to pregnant
nasal cavity. Electrical signals are then clients, and of these, 24% had recom-
transmitted to the brain by olfactory sensory mended aromatherapy.7 In Australia, a
neurons. These electrical signals stimulate large cross-sectional questionnaire con-
the limbic system (the part of the brain that ducted in 2009 surveyed a nationally
deals with emotions and memories), and by representative sample of 8200 women
doing so aromatherapy can decrease anxiety about self-prescribed use of aromather-
and reduce pain perception.4 In this regard, apy oils. About 10% (804) of the survey
choosing a fragrance that is personally respondents were pregnant at the time of
appealing may offer individualized benefits. the survey, and 15.2% of these reported
In addition, models have demonstrated that that they self-prescribed aromatherapy
the components of essential oils (when oils during pregnancy.8 However, despite
inhaled or absorbed through the skin) can its common use in the perinatal popula-
enter the systemic circulation and cross the tion, some obstetric care providers remain
blood-brain barrier.5 unaware of the research evidence on
Examining complementary and alterna- aromatherapy. Therefore, this narrative
tive medicine (CAM) therapies, such as review provides a critical synthesis of the
aromatherapy, is important because their best available evidence in the current
application can result in significant maternal literature (from within the last 10 y) on
benefits throughout the peripartum period. perinatal effects of aromatherapy.
Beneficial effects may be due in part to the
receipt of individualized, woman-centered
care, as this is a philosophy of care inherent Methods
to all CAM modalities. CAM therapies We performed a search on PubMed using
embrace the concept of “holism,” in which the key words aromatherapy AND (obstet-
the individual is viewed as a whole person rics or pregnancy or prenatal or labor or
with interlinking physical, mental, and spi- delivery or postpartum). Results were re-
ritual conditions. Aromatherapy is viewed trieved from within the last 10 years up to
as a holistic therapy, especially when ad- October 2020. This review was limited to
ministered with a manual modality such as studies published in the English language,
massage. The manual effects of the mas- and we excluded research studies on aro-
sage, when combined with the psychoemo- matherapy and breastfeeding. The search
tional effects of the essential oils, can create revealed 135 results. Criteria for the inclu-
a sense of wellbeing, thus affecting body, sion of studies were full-length, peer-re-
mind, and spirit.1 viewed meta-analyses, systematic reviews,
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randomized controlled trials (RCTs), and history of gastrointestinal disease. Studies
quasi-experimental trials that evaluated the were restricted to only those with the
effects of aromatherapy during the prenatal, strongest methodology per Jadad criteria
intrapartum, or postpartum periods. We (a score of 3 or higher of 5). The Jadad
identified 36 studies that met our criteria score is a tool used to assess the methodo-
for inclusion (10 meta-analyses/systematic logical quality of controlled trials between
reviews and 26 RCTs/quasi-experimental 0 (very poor) and 5 (rigorous).
trials). A review of this literature will be Of the 21 papers included in this review
discussed in the following sections. of complementary medicine methods, 2
assessed peppermint aromatherapy (Ja-
dad scores of 4 and 5), and one assessed
Results lemon aromatherapy (Jadad score of 5).
The first of the 2 studies on peppermint
DESCRIPTION OF STUDIES aromatherapy was a double-blinded study
We formulated search terms and screened by Pasha et al24 that randomly assigned 60
abstracts for all studies meeting the inclu- pregnant participants with nausea and vom-
sion criteria. Altogether, this review dis- iting to peppermint essential oil or normal
cusses 1 systematic review9 on nausea and saline placebo. Women in the peppermint
vomiting during pregnancy; 2 RCTs10,11 on group slept for 4 consecutive nights with a
stress reduction and immune function dur- bowl of water containing 4 drops of pure
ing pregnancy; 4 meta-analyses,2,12–14 2 peppermint essential oil placed on the floor
systematic reviews15,16 and 1 quasi-experi- near their beds, while those in the control
mental trial17 on labor pain/anxiety and group used 4 drops of saline. The research-
labor progress/outcomes; 1 meta-analysis18 ers mentioned that they attempted to blind
and 2 RCTs19,20 on postcesarean symptoms; mothers in the control group by pouring
and 2 systematic reviews21,22 and 1 RCT23 some peppermint oil into the inner parts of
on perineal trauma, postpartum sleep, and the saline container’s lid. The Visual Analog
symptoms of depression and anxiety. Sup- Scale (VAS) was used to assess the severity
plementary Table 1 (Supplemental Digital of nausea, and the frequency of vomiting
Content, http://links.lww.com/GRF/A26) was recorded before, during, and after the
details notable essential oils that demon- intervention. There was a decreasing trend
strated a significant effect for each indica- in the peppermint group that did not reach
tion compared to control in randomized statistical significance, possibly due to the
trials. small sample size. During the 4 days of
intervention, the mean of nausea intensity
PRENATAL USE OF AROMATHERAPY was 3.50 ± 1.95 and 4.38 ± 2.18 in the pep-
There is research from RCTs on the permint and saline groups, respectively
prenatal use of aromatherapy for nausea (P = 0.140). The mean of vomiting intensity
and vomiting during pregnancy, as well as during the 4-day intervention was
for stress reduction and immune function. 2.23 ± 1.88 in the peppermint group and
2.55 ± 2.55 in the saline group (P = 0.577).
Nausea and Vomiting Joulaeerad et al25 carried out a single-
We found a 2018 systematic review of blinded study comparing peppermint oil to
RCTs that investigated different comple- almond oil (placebo) and similarly found no
mentary medicine methods used to treat significant effect on the severity of nausea
nausea and vomiting during pregnancy.9 and vomiting during pregnancy. A total of
Participants had experienced nausea with 56 participants, all between 6 and 20 weeks
or without vomiting, were overall healthy, of gestation with mild to moderate nausea
with a single fetus, and without any and vomiting, were randomly assigned to
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peppermint oil or placebo. For 4 days, they from 16 to 36 weeks gestation to determine
were asked to drop 5 drops onto a cotton the effects of aromatherapy massage on
ball, hold it 1 cm below the nose, and take 3 participants’ stress levels and immune
deep breaths through the nose. They were function.10 Women with high-risk pregnan-
asked to repeat this 4 times per day when cies were excluded (ie, multiple gestations,
they felt nauseous. Nausea and vomiting fetal growth restriction, or other abnormal-
scores were assessed as a single measure ities) as well as those with a history of severe
with the Pregnancy Unique Quantification illness (including depression) or reported use
of Emesis/Nausea questionnaire. The results of medications with the potential for abuse.
showed no difference in the severity of The intervention group received routine
nausea and vomiting between placebo and prenatal care plus 70 minutes of aromather-
intervention groups during the 4-day inter- apy massage every other week for a total of
vention period. At the end of the 4 days, 10 sessions, while the control group received
mean scores were 5.18 ± 1.90 and only routine prenatal care (which did not
5.82 ± 2.14 in the peppermint oil and place- include aromatherapy or massage). A certi-
bo groups, respectively (P = 0.227). fied aromatherapist delivered the massage
Yavari Kia et al26 found a significant treatment using a combination of effleurage,
reduction in nausea and vomiting during friction, petrissage, and vibration applied
pregnancy with lemon aromatherapy with moderate pressure to the head, neck,
compared with placebo. In this double- shoulders, arms, waist, back, legs, and feet.
blinded trial, 100 participants with nausea The massage oil consisted of 2% lavender
and vomiting during pregnancy were ran- (Lavandula angustifolia) essential oil; ∼30
domly assigned to a lemon essential oil mL was used for each massage.
(Citrus lemon) or placebo (almond oil The study authors used salivary cortisol
combined with carrots to match the color (μg/dL) as an indicator of stress, and
of lemon oil). The participants had single- salivary immunoglobulin (Ig) A (μg/mL)
ton pregnancies between 6 and 16 weeks as an indicator of immune function. Saliva
gestation, with no major medical prob- samples were collected from participants in
lems. They were taught to put 2 drops both groups before and after the interven-
onto a cotton ball, hold it 3 cm below the tion group received aromatherapy massage
nose, and take 3 deep breaths through treatment. Analysis of the saliva samples
the nose whenever they felt nauseated. revealed that participants in the aroma-
The procedure could be repeated therapy massage group had lower salivary
5 minutes later. Nausea and vomiting cortisol (P < 0.001) and higher IgA
scores were assessed with the Pregnancy (P < 0.001) levels immediately after each
Unique Quantification of Emesis/Nausea treatment compared with those in the
questionnaire. The mean scores of nausea control group. In the control group, the
and vomiting were significantly lower pretest and posttest salivary cortisol and
with lemon aromatherapy on the second IgA levels were similar at each time point.
[mean deviation (MD): −1.06 (−1.94 to Aromatherapy massage also showed sig-
−0.19), P = 0.017] and fourth [MD: −1.00 nificant long-term effects in salivary IgA
(−1.95 to −0.05), P = 0.039] days of treat- levels; the pretest levels at 32 (P = 0.002)
ment. The researchers reported no ad- and 36 (P < 0.001) weeks gestation were
verse effects from the treatment and higher than the pretest IgA levels at 16
concluded that the results were promising. weeks (baseline).
In this study, they found no evidence of
Stress Reduction and Immune Function long-term effects of aromatherapy mas-
In the first study of its kind, researchers sage on salivary cortisol levels. This could
longitudinally followed 52 healthy women be due to a physiological increase in stress
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as the pregnancy progresses, particularly (P < 0.05) after the intervention. The in-
after ∼32 weeks gestation. In the control tragroup comparison suggests that aro-
group, there was a significant increase in matherapy inhalation with essential oils
pretest salivary cortisol levels between 16 high in linalool and linalyl acetate could
and 36 weeks. The frequency of aroma- significantly decrease heart rates and im-
therapy massage may need to be increased prove anxiety and anger for pregnant
after 32 weeks gestation to once or twice a women. There were, however, no differ-
week to overcome rising stress levels ences observed between intervention and
during pregnancy.10 The findings suggest control groups, so further research is
that prenatal aromatherapy massage required. There is also a need to study
could immediately relieve stress and en- these effects over longer periods of time.
hance long-term immune function. How- In this study, participants were only
ever, this study was limited by the assessed 5 minutes postintervention.
inability to separate the effects of aroma-
therapy from those of massage, and blind- INTRAPARTUM USE OF
ing was not possible given the nature of AROMATHERAPY
the intervention. We found 2 areas of research in which there
An earlier, much smaller RCT also is evidence from RCTs: labor pain and
assessed the effects of aromatherapy on anxiety, and labor progress and outcomes.
stress during pregnancy.11 This study used
the Profile of Mood States (POMS) ques- Labor Pain and Anxiety
tionnaire that measures mood states by 6 Smith et al2 conducted the first systematic
scales and heart rate measurements to review and meta-analysis specifically on
examine the physical and psychological aromatherapy for pain management in
effects of aromatherapy inhalation. A total labor and concluded there is a lack of
of 13 pregnant women in week 28 of a low- research evaluating the role of aromather-
risk pregnancy were assigned to interven- apy for labor pain management. This
tion (n = 7) or control (n = 6). Participants Cochrane review included 2 RCTs with
were asked to choose one essential oil out 535 participants. In one trial, women in
of lavender (L. angustifolia), petitgrain the experimental group could choose
[Citrus aurantium (Fe)], and bergamot from 5 essential oils: Roman chamomile
(C. aurantium). All of these essential oils (Chamaemelum nobile), clary sage (Salvia
are high in linalool and linalyl acetate, sclarea), frankincense (Boswellia carteri),
which are thought to have relaxing effects. lavender (Lavandula augustifolium), and
Pregnant women in both groups filled mandarin (Citrus reticulata), while the
out the POMS and then rested in a seated control group received standard care on-
position for 10 minutes while wearing a ly. In the other trial, the experimental
portable heart rate monitor. During the group was assigned to the essential oil of
second half of the 10-minute session, ginger and the control group received
aromatherapy inhalation was given to another essential oil (lemongrass). The
those in the intervention group. All study trials found no difference between groups
subjects were aware of their group assign- in pain intensity or epidural use.
ment. In the intervention group, the re- A more recent meta-analysis and sys-
searchers observed improvements in the tematic review by Lakhan et al12 refer-
Tension-Anxiety Score (P < 0.05) and enced the above-mentioned Cochrane
the Anger-Hostility Score (P < 0.05) of findings and included 2 new clinical trials.
the POMS after aromatherapy inhalation The first of these (n = 160) found lower
treatment. There was also an intragroup mean pain intensity with lavender com-
increase in parasympathetic nerve activity pared with control at 30 and 60 minutes
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after the intervention (P < 0.001).27 The damascena), bitter orange (C. aurantium),
second new trial (n = 126) also found lavender (L. angustifolia), geranium (Pelar-
reduced pain severity following aroma- gonium graveolens), and sweet orange (Cit-
therapy with a bitter orange (C. auranti- rus sinesis). One study had participants in
um) at 3 to 4 cm (P < 0.05), 5 to 7 cm the experimental group select from laven-
(P < 0.05), and 8 to 10 cm (P < 0.05) der, geranium rose, citrus, and jasmine,
dilatations compared with control.28 Both based on their personal preference. Another
of these studies (Kaviani and colleagues; study with 2 experimental groups assigned
Namazi and colleagues) were included in participants to jasmine (Jasminum offici-
the following 2 meta-analyses. nale) or salvia (Salvia officinalis).
A 2020 systematic review and meta- Aromatherapy was shown to reduce
analysis of 8 RCTs and 1 quasi-experimen- pain in latent (cervical dilatation of 3 to
tal study evaluated the effects of aroma- 4 cm), early active (cervical dilation 5 to 7
therapy on anxiety and pain during the first cm), and late active (cervical dilation 8 to
stage of labor in nulliparous participants.13 10 cm) phases of first-stage labor com-
Full-text trials published in English before pared with control. The corresponding
January 2019 were eligible for inclusion. VAS score reductions were MD: −1.88
Study subjects were low-risk primigravida (−2.98 to −0.78), P = 0.0008 in latent
with a singleton, cephalic pregnancy at labor (5 RCTs); MD: −1.78 (−2.83 to
term (gestational age over 37 wk) in spon- −0.72), P = 0.001 in early active labor (4
taneous first-stage labor (defined as > 3 RCTs); and MD: −1.72 (−2.69 to −0.76),
contractions in 10 min with cervical P = 0.0004 in late active labor (4 RCTs).
change). The authors used VAS to measure It is worth noting that although aroma-
pain from 0 (no pain) to 10 (worst possible therapy resulted in significantly lower
pain). To measure anxiety, they used the pain scores compared with control, mean
first 20 questions of the Spielberger’s State- pain scores were still at moderate to
Trait Anxiety Inventory questionnaire, severe levels in both groups (∼6.9 vs. 8.6
with possible scores between 20 (no anxi- in the late active phase). Epidural analge-
ety) and 80 (highest possible anxiety). sia was not typically available or used by
Trials were excluded that used different participants in these studies; therefore,
case selection criteria and measurement more research is required to assess aro-
methods. matherapy as an addition to pharmaco-
The 9 included trials were published logical analgesia.13,29 High heterogeneity
between 2010 and 2018; 7 were published was observed among the studies in each
in Iran, 1 in Taiwan, and 1 in Thailand. The comparison, which could indicate effect
studies used different methods of adminis- variation from different essential oils and
tering the aromatherapy intervention. In 5 methods of administering aromatherapy.
RCTs it was given via inhalation, while the Subgroup analysis of lavender inhalation
control group received distilled water place- (2 RCTs) found a significant reduction in
bo (4 studies) or usual care (1 study). In 3 pain in the latent phase with moderate
RCTs the experimental group received heterogeneity; however, the effect on
drops of essential oils applied to gauzes early active and late active labor was not
attached to their neck collars, while partic- statistically significant. An analysis of 4
ipants in the control groups received gauzes trials did not find a significant difference
with drops of normal saline. Finally, the between baseline pain scores (on admis-
quasi-experimental study compared with sion) in the experimental group and pain
massage with essential oil to massage with scores after the aromatherapy interven-
carrier oils alone. The essential oils admin- tion [MD: −0.67 (−2.49 to 1.16),
istered in the studies were rose (Rosa P = 0.47]. It may be that the pain-relieving
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effect before versus after aromatherapy Two systematic reviews in the last few
was masked by an inherent increase in years have assessed the effectiveness of
pain intensity with the progression of aromatherapy at managing labor pain
active labor, especially since epidurals and anxiety. Tabatabaeichehr and
were not typically utilized. Mortazavi15 evaluated 33 randomized
Aromatherapy also reduced partici- trials conducted in English and Persian.
pants’ anxiety during latent labor com- Twenty-seven of the 33 studies were
pared with control [MD: −9.29 (−15.88 to carried out in Iran. Aromatherapy was
−2.69), P = 0.006]. As with pain scores, administered with inhalation, massage,
the intragroup results comparing anxiety footbath, birthing pool, acupressure, and
before and after aromatherapy did not compress. The essential oil most com-
find a significant effect [MD: −5.64 monly used in the studies was lavender,
(−16.00 to 4.71), P = 0.29]. either alone or in combination with other
Another meta-analysis by Chen et al14 essential oils. Other essential oils used in
also found a significant reduction in pain the included studies were geranium,
scores with aromatherapy during labor. frankincense, rose, chamomile, bitter or-
Lavender was the most common oil used ange, jasmine, sweet orange, mandarin,
in these trials. The authors conducted peppermint, and clove. The majority of
separate analyses of RCTs with cervical the studies (29/33) reported that aroma-
dilation info and those without. The 6 therapy had a significant positive effect
trials with dilation info reported a wide on reducing labor pain and/or anxiety.
range of dilations but all included the 8 to No serious side effects to aromatherapy
10 cm transition phase. The aromather- were reported in any of the studies. The
apy group reported reduced pain scores in systematic review concluded that aroma-
the transition phase compared with the therapy could help in relieving maternal
control group [MD: −0.82 (−1.55 to anxiety and pain during labor.
−0.09), P = 0.03]. Meta-analysis of the 4 Ghiasi et al16 reviewed 16 randomized
trials without dilation info also showed a trials, specifically focusing on aromather-
reduction in pain scores postintervention apy to relieve anxiety during the first
[MD: −2.01 (−3.63 to −0.39), P = 0.02]. stage of labor. Aromatherapy was admin-
Our literature search also identified a istered with inhalation in 12 studies and
quasi-experimental trial by Sriasih et al17 by massage in 4 studies. Lavender was the
that was too recent to be included in any of most frequently studied oil; other oils
the meta-analyses. Participants were ran- included rose, clary sage, geranium,
domly assigned to massage with frangipani frankincense, chamomile, bitter orange,
(Plumeria) aromatherapy oil (n = 35) or sweet orange, peppermint, mandarin or-
massage with virgin coconut oil as control ange, jasmine, and clove. Of the 16
(n = 35). The massage was applied to the studies, all but 1 study found that aroma-
back region at thoracic vertebrae 10, 11, 12, therapy significantly lowered anxiety dur-
and lumbar 1 levels. Midwives began the ing the first stage of labor. The systematic
massage treatment at 4 cm and continued review recommended that aromatherapy
the massage for 5 to 6 hours until maximal could be applied as a complementary
dilation at the end of first-stage labor. therapy for reducing anxiety during the
Before the massage treatment, both groups first stage of labor; however, they cited
reported pain scores on a scale of 7 to 9 the need for more methodologically rig-
(considered severe pain). After the treat- orous studies.
ment, pain scores were significantly reduced Overall, the available evidence suggests
to a median of 7 in the control group and 6 that aromatherapy reduces pain and anxi-
in the aromatherapy group (P < 0.001). ety during the first stage of labor.
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Labor Progress and Outcomes Postcesarean Symptoms
Six trials in the Chen et al14 meta-analysis A Cochrane review on CAM for post-
reported a comparison of the duration of cesarean pain found 4 trials that exam-
the active phase of the first stage of labor. ined the effects of aromatherapy on
The results showed that aromatherapy postcesarean pain.18 All 4 studies pro-
consistently reduced the duration of the vided pharmacological analgesia in both
active phase (h) compared with control the aromatherapy groups and the control
across trials [MD: −0.69 (−1.02 to −0.36), groups. Two trials tested the effects of
P < 0.0001]. There was also a reduction in lavender versus sham lavender or place-
the duration of the third stage (min) with bo, 1 via mask inhalation and the other
aromatherapy [MD: −3.32 (−6.26 to using drops applied to cotton; 1 study
−0.38), P = 0.03]; however, high hetero- compared chamomile to placebo using
geneity across trials suggests other factors drops applied to cotton; and 1 study
such as third-stage management could compared C. aurantium to saline, also
have influenced this outcome. The analy- using drops applied to cotton. Due to
sis showed a nonsignificant trend towards differences in data collection, data from
the shorter duration of second-stage labor all 4 studies could not be pooled for most
and shorter total duration of first-stage of the outcomes. The Cochrane reviewers
labor (early phase, active phase, and found low-certainty evidence that aroma-
transition phase) with aromatherapy. therapy plus analgesia may slightly de-
Aromatherapy during labor does not crease postcesarean pain as measured by
appear to have an effect on the risk of the VAS at 12 hours [MD: −2.63 (−3.48
intrapartum cesarean or newborn Apgar to −1.77), P < 0.00001, 3 studies] and
scores, suggesting that aromatherapy can 24 hours [MD: −3.38 (−3.85 to −2.91),
be safely administered intrapartum. Six P < 0.00001, 1 study] compared with pla-
trials in the Chen et al14 meta-analysis cebo plus analgesia. One study found
compared the incidence of intrapartum lower diastolic blood pressure in the
cesarean between groups and no differ- aromatherapy group [MD: −3.62 mm
ences were observed [relative risk (RR): Hg (−6.97 to −0.27), P = 0.03], and 2
0.78 (0.48 to 1.26), P = 0.31]. Similarly, studies found a 42% reduction in RR of
the 2 trials in Smith et al2 found no using additional pain medication [RR:
difference in the duration of labor, rate 0.58 (0.45 to 0.75)]. The Cochrane re-
of cesarean, or rate of assisted vaginal viewers found uncertain effects of aroma-
birth. Three trials in the Liao et al13 meta- therapy on postcesarean anxiety (1 study)
analysis investigated aromatherapy’s po- and vital signs other than diastolic blood
tential influence on Apgar scores at 1 and pressure. There were no data on potential
5 minutes after birth. The results did not adverse events. Only 1 study measured
find a significant effect on Apgar scores. patient satisfaction; the researchers found
The studies consistently showed no effect that 90% of the aromatherapy group was
from aromatherapy on the cesarean rate satisfied, compared with 50% in the pla-
or Apgar score. cebo group (P = 0.002).
An additional double-blind RCT on
POSTPARTUM USE OF postcesarean pain published in 2019 by
AROMATHERAPY Abbasijaharomi et al19 was too new to be
We found systematic reviews and included in the Cochrane review. Ninety
randomized controlled evidence on aro- mothers who gave birth by cesarean were
matherapy for use with postcesarean randomly assigned to aromatherapy with
symptoms, perineal trauma, sleep, and lavender, aromatherapy with damask
symptoms of depression and anxiety. rose, or control with distilled water. The
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aromatherapy and control treatments Participants in all 3 groups had similar
were administered by asking the mothers levels of nausea at baseline. The aroma-
to inhale cotton balls imbibed with 3 therapy and placebo groups inhaled from
drops of oil or water for 30 minutes. a mini ziplock bag containing a cotton
Before the intervention or control, there ball with 1 mL of peppermint spirits or
was no difference in VAS pain levels sterile water, respectively. They held the
between groups (P = 0.072). Five minutes bag 2 inches under the nose and took 3
after the intervention was completed, slow, deep breaths. This intervention was
average pain levels were significantly low- conducted at baseline and again 2 and
er in both aromatherapy groups com- 5 minutes postbaseline. The nausea levels
pared with the control (damask rose: of participants in the peppermint spirits
4.97 ± 1.92; lavender: 5.80 ± 2.01; control: group were significantly lower than those
6.03 ± 1.43; P = 0.042). Five-minute post- of participants in the other 2 groups at 2
intervention pain levels were lower in the and 5 minutes after the initial intervention
damask rose group than the lavender [peppermint vs. placebo at 2 min
group; however, the lavender group had (P < 0.001) and 5 min (P < 0.001); pepper-
a trend towards the highest pain levels at mint vs. antimetic therapy at 2 min
baseline, which may explain why lavender (P = 0.001) and 5 min (P = 0.003)]. Within
did not have postintervention results as the peppermint aromatherapy group, 17
low as damask rose. of the 22 participants reported no nausea
Our literature search identified 1 small or slight nausea at 5 minutes, while every-
RCT on aromatherapy to treat postcesar- one in the placebo and standard care
ean nausea.20 Participants were invited to groups still reported moderate to extreme
take part in this study if they were nausea or “about to vomit.” The authors
scheduled for a nonemergency cesarean, concluded that peppermint spirits could
English speaking, at least 18 years of age, be a useful adjunct in the treatment of
nonsmoker, and became nauseated after postoperative nausea.
their cesarean. Anyone with an allergy to
peppermint or food colorings was ex- Perineal Trauma
cluded, as well as those diagnosed with Tsai et al21 published a systematic review of
persistent vomiting or receiving magnesi- 15 studies evaluating the effects of aroma-
um sulfate therapy. Potential participants therapy on a variety of postpartum out-
were told they would be randomly as- comes. Their paper included 5 RCTs on
signed to 1 of 3 groups: peppermint spirits postepisiotomy pain and healing. The re-
aromatherapy (Mentha piperita), sterile sults suggested that regular use of lavender
water placebo (mixed with green food inhalation and lavender added to bath-
coloring), or standard antiemetic therapy. water may have beneficial effects on wound
The “peppermint spirits” consisted of healing and pain after an episiotomy. The
ethyl alcohol 82%, peppermint oil, puri- largest study of postepisiotomy healing
fied water, and peppermint leaf extract. included in this review was published by
Thirty-five participants experienced Vakillian et al.30 This study took place in
postcesarean nausea and were randomly Iran, where nearly all primiparous women
assigned to peppermint aromatherapy who give birth vaginally have an episiot-
(n = 22), placebo (n = 8), or standard omy. Vakillian et al30 randomly assigned
antiemetic therapy (n = 5). Baseline nau- 120 postpartum women to receive lavender
sea was assessed with a 6-point nausea oil (distilled in a sitz bath twice daily for 10
scale immediately before administering d) versus povidone-iodine wound care,
the interventions and reassessed 2 and which is routinely recommended for post-
5 minutes after the initial intervention. episiotomy care in Iran. Ten days after
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entering the study, there was a trend scores on the individual subscales of red-
towards more people with zero pain in ness, edema, and discharge.
the lavender oil group (41.7% vs. 28.3%),
and fewer people with severe pain in the Sleep
lavender oil group (13.3% vs. 30%), but the We found 2 systematic reviews on aro-
result was not statistically significant matherapy for postpartum sleep. The
(P = 0.063). Examination results from a Rezai-Keikhai et al’s22 review included 3
blinded midwife showed more people had randomized trials, while Tsai et al21 ex-
zero redness in the lavender oil group amined only 2 of those studies and ex-
(51.7% vs. 21.7%, P = 0.001), but there cluded the third because it did not test
were no differences between groups in rates true aromatherapy. In the first study
of edema, dehiscence, or infections. included in the Tsai and colleagues’ re-
We found one study that was not view, Keshavarz Afshar et al31 enrolled
published in the Tsai et al’s review; this 158 healthy, nondepressed mothers who
trial took place in Egypt, which also has were exclusively breastfeeding their in-
extremely high rates of episiotomy. In fants and had poor quality sleep as meas-
this RCT, Marzouk et al23 analyzed data ured by the Pittsburgh Sleep Quality
from 60 women who were randomly Index score (a scale from 0 to 21 with
assigned to aromatherapy with lavender higher scores indicating worse sleep qual-
or placebo with saline. The aromatherapy ity). During the first week, postpartum,
group was instructed to use a sitz bath participants randomly assigned to the
twice daily for 7 days; women were given aromatherapy group were instructed to
a solution of 2% lavender-thymol (1:1) put 4 drops of lavender oil on a cotton
dissolved in jojoba oil, and they were ball and place it in a container about 20
instructed to mix it with 4 L of warm cm away. They took 10 deep breaths, then
water. The control group followed similar placed the container by their pillow until
instructions but added a prepared solu- morning. The placebo group followed the
tion containing 10 mL of saline to the 4 L same instructions but used a placebo oil
of warm tap water. All women received a instead. Eight weeks after beginning the
postpartum home visit on day 7 and week study protocol, sleep quality was signifi-
7 to evaluate incision healing and pain. cantly improved in the aromatherapy
The mean VAS pain scores were signifi- group (from 8.29 ± 2.12 down to
cantly lower in the aromatherapy group 6.80 ± 2.37, P < 0.05), but not in the con-
at 7 days (2.1 ± 2.2 vs. 3.5 ± 1.9, trol group (8.46 ± 2.3 to 7.57 ± 1.15,
P = 0.011), and dyspareunia was more P > 0.05). Eight-week postintervention
severe in the placebo group (5.3 ± 2.7 vs. sleep quality was also significantly im-
2.7 ± 1.5, P < 0.001). proved in the aromatherapy group com-
An examination of analgesic use from pared with the control group (6.80 ± 2.37
the first 3 days postpartum revealed more vs. 7.60 ± 1.15, P = 0.033).
analgesic use in the placebo group than In the second randomized trial on
the aromatherapy group. Wound healing aromatherapy for postpartum sleep,
was also better in the aromatherapy Mirghafourvand et al32 randomly as-
group—on day 7 the aromatherapy group signed 96 women in the first week post-
had a significantly better (lower) overall partum to ingest placebo or essential oils.
Redness, Edema, Ecchymosis, Discharge, Women were excluded if they had a
and Approximation (REEDA) score diagnosis of depression during pregnancy.
(a measurement of perineal healing) com- The aromatherapy intervention consisted
pared with the placebo-treated group of drinking a glass of water with 10 drops
(2.03 vs. 3.93, P = 0.013), as well as better essential orange peel oil (C. sinensis L.), 3
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times daily for 8 weeks. The placebo was The researchers measured stress, anxiety,
similar in appearance and odor to the and depressive symptoms (21-item De-
orange peel oil and ingested using the pression, Anxiety, and Stress Scale and
same protocol; the study was triple- the Edinburgh Postnatal Depression
blinded. Sleep quality was measured with Scale) at 2 weeks, 1 month, and 3 months
the Pittsburgh Sleep Quality Index. At 8 postpartum. The authors did not report
weeks, after controlling for the baseline baseline levels of depression and anxiety.
sleep score, sleep quality was significantly Average scores of stress, depression, and
improved in the aromatherapy group anxiety were significantly lower in the
(MD = 5.0, 95% confidence interval: 3.9- aromatherapy group at all 3 follow-up
6.1, P = 0.001). In terms of side effects, time points. For example, at 3 months,
study participants reported similar levels the aromatherapy group had significantly
of dizziness in both groups. The control lower stress levels (3.81 ± 3.48 vs.
group had reports of heart palpitations 7.27 ± 5.11, P = 0.001), anxiety levels
(9.3%) and nausea (4.2%), while the ar- (1.23 ± 1.94 vs. 4.13 ± 3.43, P = 0.001),
omatherapy group reported increased uri- and depressive symptoms (2.13 ± 2.44 vs.
nation (10.4%). 5.07 ± 3.97, P = 0.001). Furthermore, the
distribution of depression was signifi-
Symptoms of Depression and Anxiety cantly lower in the aromatherapy group
We found 2 systematic reviews evaluating at 2 weeks (18.6% vs. 35.7%, P = 0.023),
the effects of aromatherapy on postpar- 1 month (2.9% vs. 30%, P = 0.001), and
tum mental health (Rezaie-Keikhaie and 3 months (4.3% vs. 24.3%, P = 0.001).
colleagues; Tsai and colleagues), with the Although the results are significant, this
Tsai and colleagues’ review being more study is limited by its lack of a placebo
comprehensive and of higher quality.21,22 treatment.
Tsai and colleagues assessed the quality of Although 3 of the trials in the Tsai and
studies using the modified Jadad scale, in colleagues’ review show promising results for
which studies are scored between 0 (the aromatherapy’s effects on postpartum psy-
lowest quality) and 8 (the highest quality); chological symptoms, 2 trials—testing a
the review authors considered all studies lavender-infused bath and citrus-imbibed
scored ≥ 4 to be “high” quality. Tsai and drink—did not find any significant effects
colleagues found mixed results on the from aromatherapy on depression and anxi-
effects of aromatherapy on psychological ety. In a high-quality study (modified Jadad
health postpartum. Three studies of inha- score of 6), Mirghafourvand and colleagues
lation aromatherapy of either lavender or carried out a double-blinded, RCT testing
C. aurantium found improved symptoms the effects of ingesting orange peel essential
of depression or anxiety levels. The largest oil (C. sinensis L.) in 96 postpartum women
of these trials (n = 140) was published by without a history of depression. The trial
Kianpour et al33 (modified Jadad score of protocol was previously described in the sleep
4). Immediately after giving birth, partic- section of this paper; the sleep results were
ipants in Iran were randomly assigned published separately from the depression
to aromatherapy or routine care after results. In contrast to the findings from
discharge (no placebo was used). The Kianpour and colleagues, Mirghafourvand
researchers excluded anyone with preg- and colleagues did not find any differences
nancy complications. The aromatherapy between aromatherapy and placebo groups
group was instructed to put 3 drops of in depression (as measured by the Edinburgh
lavender oil on their palms, rub them Postanal Depression Scale) or state/trait
together, and inhale. This process was anxiety (as measured by the State-Trait
carried out 3 times daily for 4 weeks. Anxiety Inventory questionnaire) at 8 weeks
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postpartum. Depressive symptoms improved postpartum periods. Although 2 trials
in both groups over time (aromatherapy: have found that peppermint oil did not
8 ± 3.6 to 6.7 ± 4.8; placebo: 8.1 ± 3.3 to reduce prenatal nausea and vomiting, 1
6.7 ± 4.9; P = 0.005) but there was no differ- randomized trial found promising results
ence between groups (P = 0.925). State and for lemon oil inhalation.23 Another
trait anxiety scores were similar at baseline randomized trial found that prenatal
and 8 weeks postpartum in both groups. massage with lavender essential oil had
immediate effects on stress relief, as well
as a beneficial effect on long-term im-
Discussion mune function.10
The physiological effects of aromatherapy Aromatherapy (administered either via
are best understood from a holistic point of body massage or inhalation) appears bene-
view, in that the whole “package” should be ficial at reducing pain throughout the entire
considered instead of just its parts. To start first stage of labor and reducing anxiety
with, each essential oil contains many during the latent phase of first-stage labor.13
chemical constituents in various proportions The intervention has unknown effects on
to form its chemical profile. The oil’s anxiety in second-stage and third-stage la-
chemical profile is affected by climate, bor. In addition, aromatherapy may be
altitude, seasons, and the plant’s growing beneficial in reducing the duration of the
conditions; deterioration occurs over time active phase of first-stage labor and the
with exposure to air (oxidation), heat, and duration of the third stage compared with
ultraviolet light.1 Next, the method, dose, control.14 Aromatherapy during labor has
and frequency of administration influence not demonstrated an effect on the risk of
the effects of aromatherapy. For example, intrapartum cesarean or newborn Apgar
hot water and steam from a bath or foot- scores.13,14
bath encourages greater absorption of es- Aromatherapy (administered via drops
sential oils via the skin and via the on cotton or with a mask) plus analgesia
respiratory tract; likewise, massage enhan- may slightly decrease pain at 12 and
ces absorption due to increased blood flow 24 hours after a cesarean compared with
from manipulating the skin and via the placebo plus analgesia.18 Lavender oil
inhalation of vaporized molecules.1 Meth- added to sitz baths may benefit wound
ods of administration that combine CAM healing and pain after an episiotomy.21,23
therapies may have a beneficial synergistic Aromatherapy has unknown effects on
effect, such as aromatherapy with hydro- perineal tears; therefore, more research is
therapy, or aromatherapy with massage needed to see if aromatherapy would be
therapy. Importantly, the mother’s involve- beneficial when caring for tears unrelated
ment in decision-making (autonomy), any to episiotomy use. However, given the
additional support from care providers, and benefits seen in postepisiotomy trials, it’s
the quality of the care provider-patient possible that it may be beneficial with
relationship may also influence the thera- other types of perineal trauma. In terms
peutic effects of aromatherapy. Finally, of postpartum sleep, lavender inhalation
individual recipients may respond differ- seemed to confer benefits on sleep
ently to aromatherapy because of personal quality.31 These results are consistent with
characteristics affecting bioavailability (ie, research showing a positive effect of
age, metabolism, skin integrity) and because lavender aromatherapy on sleep quality
of their unique psychology. in other populations.34,35
Overall, we found evidence that aro- A growing number of researchers have
matherapy can positively impact out- also evaluated the effects of aromatherapy
comes in the prenatal, intrapartum, and on symptoms of depression and anxiety
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after giving birth. So far, inhalation of use of pain medication, this could lead to
lavender and C. aurantium have been found a lower cost of care. The authors reported
to be helpful in randomized trials, while that a year’s supply of aromatherapy and
lavender-infused baths and ingestion of massage oils cost about $500 at a center
citrus oils have not been shown to be with 3000 births per year. For a compre-
effective.21 More high-quality research on hensive discussion of aromatherapy in
aromatherapy and postpartum mental maternity care and how to implement
health is needed, particularly with placebo- aromatherapy in practice, see the study by
control, blinding, and transparent reporting Tiran.1
of randomization techniques.
Missing from the research are the POTENTIAL RISKS AND SAFETY
voices of birthing people, as we were not PRECAUTIONS
able to find any qualitative studies on the Essential oils are highly concentrated
use of aromatherapy in the peripartum chemicals that work in the same way as
period. However, there are several older pharmacologic drugs once absorbed in
studies that include some questions re- the body. In a professional handbook
lated to satisfaction and reasons for using authored by Tiran, the author writes that
aromatherapy. In 2000, a British prospec- there is a misconception that aromather-
tive study by Burns et al36 found that apy simply involves the use of fragrant
> 50% of mothers (n = 8058) rated aro- oils.1 Instead, essential oils are very
matherapy as helpful for coping with powerful and can be potentially hazard-
labor. In this study, 10 different essential ous if used inappropriately. While most
oils were used, based on consultation with oils are suitable for use in clinical aroma-
an aromatherapist: rose (Rosa centifolia), therapy, including during pregnancy,
jasmine (Jasminum grandiflorum), chamo- some are contraindicated.1,38,39 For ex-
mile (C. nobile), eucalyptus (Eucalyptus ample, oils from sweet birch (Betula lenta)
globulus), lemon (Citrus limonum), man- and wintergreen (Gaultheria procumbens)
darin (C. reticulata), clary sage (S. sclar- can cause salicylate toxicity similar to
ea), frankincense (B. carteri), lavender overdose from aspirin. Oils that contain
(L. angustifolia) and peppermint (Mentha high levels of phenols, such as cinnamon
piperita). Of these, rose oil was rated most bark (Cinnamomum camphora) and clove
highly by mothers for coping with labor bud, leaf, or stem (Syzygium aromati-
(71%), followed by lavender (50%), and cum), are also generally contraindicated
frankincense (44%). Peppermint oil was because of high potential for skin irrita-
rated as highly effective for nausea and/or tion.
vomiting during labor. In another study, All essential oils are toxic at high doses.
researchers from the UK found in a The clinical guidelines by Tiran recom-
retrospective analysis that women who mend dosages of 1% to 1.5% in pregnancy
used an aromatherapy and massage intra- (1 drop of essential oil to 5 mL carrier oil,
partum service (AMIS) had significantly with grape seed being one of the most
lower rates of epidural anesthesia, spinal popular and inexpensive carrier oils), and
anesthesia, and general anesthesia com- 2% during labor and the postpartum
pared with those who did not use AMIS period (2 drops of essential oil to 5 mL
after adjustment for parity.37 The most carrier oil).1 No > 3 essential oils should
commonly reported reasons for using be used in a blend so that problematic oils
AMIS were for relaxation/calming can be quickly identified. For hydrother-
(29.9%, n = 645) and pain relief (29.6%, apy, 4 to 6 drops of essential oil in 2 mL of
n = 638). The researchers proposed that if carrier oil can be added while running a
aromatherapy during labor decreases the bath (not in the presence of ruptured
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Copyright r 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.14 Bertone and Dekker membranes), while 3 to 4 drops can be reactions, clinicians are advised to take a mixed into a footbath. It is thought that medical history about the client’s skin vaporizers should be used for no > 10 to condition and any sensitivities or 15 minutes at a time (as overuse may allergies.1 Taking care to dilute the oil desensitize the recipient to the effects of appropriately is for the client’s benefit as the essential oils and potentially lead to well as the care provider, who may also be nausea, headaches, and drowsiness); va- at risk of dermatitis from frequent expo- porizers should only be used after careful sure. Photosensitivity is a potential side consideration of all individuals who effect of essential oils, especially with might be exposed to the vapors. Admin- citrus oils (including C. lemon and C. istering essential oils via the mucus mem- aurantium). Although citrus oils are branes (oral, vaginal, or rectal) during among the safest oils for use in pregnancy, pregnancy is not recommended. It is it is best to avoid strong sun exposure for important to purchase oils from a repu- a few hours after dermal application.1 table supplier to avoid adulteration with It is outside the scope of this review to lower quality substances. provide complete profiles on essential There is a lack of evidence on the safety of oils; more detailed information can be specific essential oils in the peripartum peri- found in professional handbooks.1 Aro- od. However, no adverse events were re- matherapy may not be appropriate for ported in any of the included studies2,9,12,15 people with certain medical or pregnancy- and there was no evidence of an effect on related complications, or with particular Apgar scores13 or the rate of cesareans.2,14 In medications. For example, aromatherapy 2000, Burns et al36 published a large pro- is considered contraindicated with epi- spective study that followed 8058 mothers lepsy, major respiratory disorders, major who gave informed consent to receive aro- cardiac disease, liver/gallbladder/kidney matherapy during labor at a British teaching disorders, and insulin-dependent diabetes. hospital between 1990 and 1998. Overall, Note that caution is needed when using only 1% of mothers reported undesired lavender with hypotension or with epi- effects from aromatherapy. The reports were dural anesthesia as it may lower blood typical of symptoms commonly reported pressure. Rose oil should be avoided until during labor, so it is impossible to know the late third trimester because of a whether the symptoms were caused by the possible mild emmenagoguic effect (herb- aromatherapy. Also, the symptoms in this al emmenagogues were traditionally used study might have been related to pharmaco- as abortifacients). Clary sage, also, should logic analgesia—when the study began in be avoided until term due to a possible 1990, 13% of mothers who used aromather- effect on uterine action.1 apy also used pethidine; however, by 1997 this figure was
Aromatherapy in Obstetrics 15
those of combination interventions such authors called the evidence “low-certainty”
as massage therapy and hydrotherapy. due to the risk of bias. The evidence on
Second, the majority of trials on aroma- using aromatherapy to treat postcesarean
therapy during the peripartum period nausea is limited to 1 small RCT. Finally,
were conducted in the Middle East (most there is limited data on which specific
notably Iran), which may limit general- essential oils are best for different clinical
izability to other populations with differ- indications; lavender oil was featured in
ent perinatal practices. Third, another many studies, however, this may be more
limitation is that very few studies have a sign of its popularity rather than superior
been conducted for several of the clinical clinical effectiveness.1 Future trials should
indications. For example, the supportive be conducted in diverse settings with a large
evidence on aromatherapy to treat nausea enough sample size to detect effects on
and vomiting during pregnancy comes clinical outcomes. Studies with random
from a single trial on lemon oil. Similarly, assignment to several different essential oils
we identified only one trial on lavender and methods of administration may be
aromatherapy to reduce stress and en- especially useful.
hance immune function during preg- However, despite these research limi-
nancy. Stronger evidence from future tations, the essential oils covered in the
RCTs and meta-analyses will be neces- reviewed studies were not shown to cause
sary to build on current findings. harm during the perinatal period. The use
Furthermore, although researchers have of aromatherapy appears to be accepted
attempted double-blinded trials of aroma- by clients as helpful for coping with
therapy (ie, with normal saline placebo, nausea/vomiting and stress during preg-
almond oil placebo), blinding may have been nancy, labor pain, and anxiety, and post-
inadequate given the nature of the interven- cesarean symptoms, perineal trauma,
tion. However, determining the impact of the sleep quality, and depression/anxiety.
placebo effect on the effectiveness of aroma-
therapy may be less important with this
treatment, as aromatherapy intervention is Conclusions
low cost and appears to have few adverse In the past 10 years, a growing body of
effects,40 although few studies have examined research has demonstrated the potential
specific safety outcomes with aromatherapy benefits of aromatherapy during the peri-
during the peripartum period. natal period. Obstetric providers should
The authors of the Liao and colleagues’ be aware that pregnant clients in their
meta-analysis described the general quality care might be using this modality during
of studies on aromatherapy for labor pain pregnancy, labor, and postpartum. Sim-
and anxiety as “moderate” because of ilarly, there is a need for more open
weaknesses in methodology and the imprac- communication between pregnant people
tical of blinding. None of the 9 included and care providers about aromatherapy
trials in the Liao et al13 meta-analysis were use, as well as a need for provider training
double-blinded. There was also high hetero- on aromatherapy (and other CAM mo-
geneity across the trials, and this limitation dalities). To attain a more holistic set of
requires further exploration in subgroup skills and knowledge, obstetric care pro-
analyses. Therefore, more clinical trials with viders should understand the reasons why
high methodological quality are needed clients may seek aromatherapy during the
before strong recommendations regarding peripartum period, contraindications and
efficacy can be made to expectant parents precautions regarding aromatherapy, and
and clinicians. As far as using aromatherapy the evidence on aromatherapy for a vari-
to decrease postcesarean pain, the Cochrane ety of indications.
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