|Year : 2018 | Volume
| Issue : 2 | Page : 45-49
The effects of inhalation aromatherapy with Boswellia carterii essential oil on the intensity of labor pain among nulliparous women
Sara Esmaelzadeh-Saeieh1, Mitra Rahimzadeh2, Nafiseh Khosravi-Dehaghi3, Shokufeh Torkashvand4
1 Social Determinants of Health Research Center, Alborz University of Medical Sciences; Department of Midwifery, School of Nursing and Midwifery, Alborz University of Medical Sciences, Karaj, Iran
2 Social Determinants of Health Research Center, Alborz University of Medical Sciences, Karaj, Iran
3 Evidence-Based Phytotherapy & Complementary Medicine Research Center, Alborz University of Medical Sciences; Department of Pharmacognosy, School of Pharmacy, Alborz University of Medical Sciences, Karaj, Iran
4 Department of Midwifery, School of Nursing and Midwifery, Alborz University of Medical Sciences, Karaj, Iran
|Date of Web Publication||22-Mar-2018|
Dr Sara Esmaelzadeh-Saeieh
Social Determinants of Health research Center, Nursing and Midwifery Faculty, Alborz University of Medical Sciences, Karaj
Source of Support: None, Conflict of Interest: None
Background: Labor pain is a major reason behind preferring cesarean section over normal vaginal delivery. Aromatherapy is among the most common nonpharmacological therapies for pain. Objectives: The objective of this study aimed to evaluate the effects of inhalation aromatherapy with Boswellia carterii (BC) essential oil on the intensity of labor pain among nulliparous women. Methods: This randomized controlled trial was carried out on 126 nulliparous women. Women were randomly allocated to an aromatherapy (n = 63) and a placebo (n = 63) group. For each woman in the aromatherapy group, a piece of gauze was soaked with 0.2 ml of 0.2% BC essential oil diluted in 2 ml of normal saline, and then, it was attached to the collar of each woman. The intervention was repeated for each woman every 30 min up to a cervical dilation of 10 cm. The intervention in the placebo group was the same as the aromatherapy group except that the gauze was soaked only with 2 ml of normal saline. A numeric pain rating scale was used to assess the labor pain intensity before the intervention and at cervical dilations of 3–4, 5–7, and 8–10 cm. Statistical analyses were performed using descriptive and inferential statistics such as the Chi-square, the independent sample t- test, and paired t-test. Results: Between-group comparisons revealed that labor pain intensity in the aromatherapy group was significantly lower than the control group at cervical dilations of 3–4 (4.98 ± 0.93 vs. 6.68 ± 1.28, P < 0.001), 5–7 (5.79 ± 1.13 vs. 7.23 ± 1.54, <0.001), and 8–10 cm (6.35 ± 1.63 vs. 7.71 ± 1.38, P < 0.05). However, there were no significant between-group differences regarding 1 and 5 min Apgar scores (P > 0.05). Conclusion: Inhalation aromatherapy with BC essential oil has positive effects on labor pain. Therefore, it can be used for relieving labor pain in the first stage of labor.
Keywords: Aromatherapy, Boswellia carterii, Labor, Nulliparous, Pain
|How to cite this article:|
Esmaelzadeh-Saeieh S, Rahimzadeh M, Khosravi-Dehaghi N, Torkashvand S. The effects of inhalation aromatherapy with Boswellia carterii essential oil on the intensity of labor pain among nulliparous women. Nurs Midwifery Stud 2018;7:45-9
|How to cite this URL:|
Esmaelzadeh-Saeieh S, Rahimzadeh M, Khosravi-Dehaghi N, Torkashvand S. The effects of inhalation aromatherapy with Boswellia carterii essential oil on the intensity of labor pain among nulliparous women. Nurs Midwifery Stud [serial online] 2018 [cited 2022 Jul 7];7:45-9. Available from: https://www.nmsjournal.com/text.asp?2018/7/2/45/228318
| Introduction|| |
Childbirth or labor has always been one of the most serious physical and mental challenges  and one of the most painful experiences for women. Labor pain management is a main objective of midwifery care because it can positively affect women's decision to give birth vaginally., There are different pharmacological and nonpharmacological therapies for labor pain management. Nonpharmacological therapies are mostly cheaper and noninvasive and thus are usually preferred to pharmacological ones.
One of the nonpharmacological therapies is aromatherapy. The most common types of aromatherapy during labor include aromatherapy massage, aromatherapy bath, and inhalation aromatherapy. The effects of aromatherapy on labor pain have been studied more than other types of pain. However, the results of studies are contradictory. A review of randomized controlled trials found no difference in pain intensity, rate of cesarean section, or frequency of requests for pharmacological intervention for women being treated with aromatherapy compared to women receiving routine care. However, two studies found that women who received aromatherapy during labor reported a lower intensity of pain than women in a control group.,
Frankincense, scientifically known as Boswellia carterii (BC), is a medicinal plant from the Burseraceae family. BC essential oil has a warm and sparkling aroma and has a variety of health benefits such as chronic stress and anxiety alleviation, pain and inflammation reduction, and immunity boost. Moreover, the plant contains boswellic acids and pentacyclic triterpene which are similar to steroids in chemical structure. Some studies show that BC can potentially relieve pain and reduce inflammation. Despite BC painkiller effect, no study is available about the effect of BC on labor pain.
This study aimed to evaluate the effects of inhalation aromatherapy with BC essential oil on the intensity of labor pain among nulliparous women.
| Methods|| |
This was a randomized controlled trial. Based on the results of a study by Fahami et al. and with a pain standard deviation of 1.5, a pain intensity reduction of 0.75, a power of 80%, and a confidence level of 95%, a sample of 63 women were estimated to be required for each study group. Accordingly, 126 eligible women were recruited to the study from Kamali Hospital, Karaj, Iran. The sampling was done from June to September 2015. The inclusion criteria were Iranian nationality, nulliparity, term pregnancy, singleton pregnancy, cephalic presentation, spontaneous uterine contractions, cervical dilation of 3–4 cm, no obstetric complications, and no history of allergy to herbal ingredients and receiving no pain medications during the last 8 h before the study. The only exclusion criterion was a need for the emergency cesarean section.
A time-clustered sampling method was used to recruit the participants in the study groups. For this reason, during the study, weekdays were randomly allocated to either the aromatherapy or the placebo days. Accordingly, women who referred to the study setting in aromatherapy days were allocated to the aromatherapy group while women who referred in placebo days were allocated to the placebo group. Women were not blind to the study intervention. However, the biostatistician who analyzed the data was unaware of the group allocation.
Data gathering instruments were a demographic and obstetric characteristics questionnaire (with items such as age, educational and employment status, pregnancy wantedness, prenatal medical visits, and participation in childbirth preparation classes), an examination checklist, and a numeric pain rating scale. The items of the examination checklist were related to Bishop score, mother's vital signs, and Apgar score. The content validity of the checklist was confirmed by 10 faculty members of Alborz Faculty of Nursing and Midwifery, Karaj, Iran. Moreover, its reliability was evaluated using the interobserver method, during which the first author and an experienced research assistant simultaneously assessed 10 women using the checklist. The interobserver correlation coefficient was 0.86. The numeric pain rating scale was used for labor pain assessment. The scale was a ruler-like scale numbered from 0 (no pain) to 10 (the most intense pain). Numeric pain rating scales have been reported to have acceptable validity.
A midwife was trained about aromatherapy technique by the first and the third authors. She used either BC essential oil or placebo for women in the intervention or the control group, respectively. The trained midwife presented at the hospital setting in designed dates and performed sampling in the afternoon and night shifts, that the number of mothers who referred for delivery is higher than morning shifts.
BC essential oil was extracted using the hydrodistillation technique (Zarband Pharmaceutical Co., Tehran, Iran). A piece of gauze was soaked with 0.2 ml of 0.2% BC essential oil diluted in 2 ml of normal saline, and then, it was attached to the collar of each woman. For women in the placebo group, the gauze was soaked just with 2 ml of normal saline. The intervention was repeated for each woman every 30 min up to a cervical dilation of 10 cm. Another midwife assessed uterine contractions and fetal heart rate, performed vaginal examinations, adjusted oxytocin infusion rate, and calculated Apgar score. Moreover, she assessed labor pain intensity before the intervention and at cervical dilations of 3–4, 5–7, and 8–10 cm.
The study was registered in the Iranian Registry of Clinical trials (registration code: IRCT2015012020719N2). Furthermore, the Institutional Review Board and the Ethics Committee of Alborz University of Medical Sciences, Karaj, Iran, approved the study (approval codes: 2505847 and 2498142, respectively). All women were ensured about the confidentiality of their personal information. All of them provided informed consent for participation. We attempted to protect patient's rights according to the Declaration of Helsinki.
Statistical analyses were performed using the SPSS software v. 13.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics measures such as the measures of central tendency and dispersion as well as frequency distributions were used for data description. The Kolmogorov–Smirnov test showed that all study variables had a normal distribution. Therefore, between-group comparisons respecting numerical variables (such as age, fetal weight, duration of uterine contractions, and pain intensity) were performed through the independent-sample t-test. Moreover, paired t-test was used for within-group comparisons of the pain intensity. The Chi-square test was also performed for between-group comparisons respecting nominal and ordinal data (such as education level, employment status, pregnancy wantedness, prenatal medical visits, Bishop score, and participation in childbirth preparation classes). P < 0.05 was considered statistically significant.
| Results|| |
Primarily, 63 women were recruited to each study group – 126 in total. During the study, two women withdrew from the study due to lack of labor progress [Figure 1]. At baseline, the groups did not significantly differ from each other respecting their demographic and obstetric characteristics [P > 0.05; [Table 1].
Between-group comparisons revealed that labor pain intensity in the aromatherapy group was significantly lower than the control group at cervical dilations of 3–4, 5–7, and 8–10 cm [P < 0.05; [Table 2]. However, there were no significant between-group differences regarding 1 and 5 min Apgar scores [P > 0.05; [Table 3]. We found no side effect of BC in mothers and their infants during the study.
| Discussion|| |
The findings of the present study showed that inhalation aromatherapy with BC essential oil significantly reduced labor pain. BC may relieve pain through reducing blood stasis and promoting circulation. More than three hundreds volatile substances have been detected so far in BC essential oil; the most common of them are alpha-pinene, 1-octanol, linalool, limonene, octyl acetate, alpha-thujene, and (E)-beta-ocimene. Most terpenes, such as alpha-pinene and linalool have been found to have analgesic effects. An earlier study showed the effectiveness of BC extracts on neuropathic pain in animal mode. In line with our findings, a study in Italy also showed the effectiveness of BC essential oil in relieving labor pain. Another study on 8058 women revealed that 60% of women and midwives found lavender and BC aromatherapies effective. Two other studies also supported the analgesic effects of BC., Moreover, two studies reported that aromatherapy has positive effects on pain during the first stage of labor.,, Conversely, a review study on two randomized controlled trials on more than 500 women indicated that aromatherapy did not significantly reduce labor pain. This contradiction may be due to the differences in aromatherapy protocols and the types of aromas.
The present study also showed that aromatherapy with BC essential oil had no significant effects on the duration and the interval of uterine contractions. Two other studies also reported the same finding., However, another study on a limited number of women reported that the aromatherapy effect uterine contraction activity.
A study showed that the perceived quality of an aroma is the most significant factor behind individuals' responses to aromatherapy. Cognitive or psychological mechanisms for odor transduction may confound the pharmacological effects of aromatherapy. Depending on the type of the aroma, nerve cells release different neurotransmitters such as endorphins, serotonin, and noradrenaline. These neurotransmitters can relieve pain. Moreover, aromatherapy decreases corticotropin-releasing hormone through affecting olfactory pathways in the hypothalamus and thereby, alleviating anxiety. Anxiety has been found to have a direct relationship with labor pain  in that it can increase pain sensitivity and decrease pain tolerance.
Memory is another factor contributing to the effects of aromas. Each aroma can evoke certain memories and cause individuals to review the details of the last events. Therefore, each aroma can cause certain effects through its associated memories. This fact highlights the necessity of evaluating the effects of different aromas.
The other finding of the present study was the insignificant effects of aromatherapy on 1 and 5 min Apgar scores. Consistent with this finding, the results of a study also showed that aromatherapy with Roman chamomile, clary sage, BC, lavender, and mandarin had no significant effects on 1, 5, and 10 min Apgar scores.
One of the study limitations was our inability to blind participants to the study intervention because participants in the aromatherapy group could easily understand that they were being treated with something aromatic. This limitation might have affected study results.
| Conclusion|| |
The results of this study demonstrate that inhalation aromatherapy with BC essential oil has positive effects on labor pain. Aromatherapy is a safe and noninvasive nonpharmacological therapy and therefore can be used for relieving labor pain in the first stage of labor.
We also appreciate the fruitful collaboration of the participating mothers and the staffs of Kamali hospital, Karaj, Iran.
Financial support and sponsorship
The research group would like to thank the Research Administration of Alborz University of Medical Sciences, Karaj, Iran, for its financial support of the study.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Smith CA, Collins CT, Crowther CA. Aromatherapy for pain management in labour. Cochrane Database Syst Rev 2011;7:CD009215.
Hajiamini Z, Masoud SN, Ebadi A, Mahboubh A, Matin AA. Comparing the effects of ice massage and acupressure on labor pain reduction. Complement Ther Clin Pract 2012;18:169-72.
Kelner M, Wellman B. Complementary and Alternative Medicine: Challenge and Change. London: Routledge; 2014.
Saghiri M, Sattarzadeh N, Tabrizi N, Pezeshki Z. A comparative study on the severity of labor pain with or without Entonox and it's effects on the new-borns of primiparas. J Ardabil Univ Med Sci 2008;8:62-7.
Steflitsch W, Steflitsch M. Clinical aromatherapy. J Mens Health 2008;5:74-85.
Lakhan SE, Sheafer H, Tepper D. The effectiveness of aromatherapy in reducing pain: A Systematic review and meta-analysis. Pain Res Treat 2016;2016:8158693.
Namazi M, Amir Ali Akbari S, Mojab F, Talebi A, Alavi Majd H, Jannesari S, et al
. Effects of Citrus aurantium (bitter orange) on the severity of first-stage labor pain. Iran J Pharm Res 2014;13:1011-8.
Kaviani M, Azima S, Alavi N, Tabaei MH. The effect of lavender aromatherapy on pain perception and intrapartum outcome in primiparous women. Br J Midwifery 2014;22:30-3.
Axe J. What is frankincense good for? 8 essential oil uses. In: Axe, editor. Food is Medicine. Austin: Axe Wellness, LLC; 2015. Available from: available at: https://draxe.com/what-is-frankincense
. [Last accessed on 2018 Feb 06].
Hamidpour R, Hamidpour S, Hamidpour M, Shahlari M. Frankincense (rǔ xiāng; Boswellia
species): From the selection of traditional applications to the novel phytotherapy for the prevention and treatment of serious diseases. J Tradit Complement Med 2013;3:221-6.
] [Full text]
Fahami F, Behmanesh F, Valiani M, Ashouri E. Effect of heat therapy on pain severity in primigravida women. Iran J Nurs Midwifery Res 2011;16:113-6.
Good M, Stiller C, Zauszniewski JA, Anderson GC, Stanton-Hicks M, Grass JA, et al
. Sensation and distress of pain scales: Reliability, validity, and sensitivity. J Nurs Meas 2001;9:219-38.
Burns E, Zobbi V, Panzeri D, Oskrochi R, Regalia A. Aromatherapy in childbirth: A pilot randomised controlled trial. BJOG 2007;114:838-44.
Batista PA, Werner MF, Oliveira EC, Burgos L, Pereira P, Brum LF, et al
. The antinociceptive effect of (-)-linalool in models of chronic inflammatory and neuropathic hypersensitivity in mice. J Pain 2010;11:1222-9.
Pan YN, Liang XX, Niu LY, Wang YN, Tong X, Hua HM, et al
. Comparative studies of pharmacokinetics and anticoagulatory effect in rats after oral administration of frankincense and its processed products. J Ethnopharmacol 2015;172:118-23.
Hu D, Wang C, Li F, Su S, Yang N, Yang Y, et al
. A combined water extract of frankincense and myrrh alleviates neuropathic pain in mice via modulation of TRPV1. Neural Plast 2017;2017:3710821.
Storksen HT, Eberhard-Gran M, Garthus-Niegel S, Eskild A. Fear of childbirth; the relation to anxiety and depression. Acta Obstet Gynecol Scand 2012;91:237-42.
Emami Razavi Z, Karimi M. The efficacy and safety of topical Oliban oil in relieving the symptoms of knee pain (vajaol-rakbe). J Islamic Iran Tradit Med 2012;3:183-90.
Prabhavathi K, Chandra US, Soanker R, Rani PU. A randomized, double blind, placebo controlled, cross over study to evaluate the analgesic activity of Boswellia serrata
in healthy volunteers using mechanical pain model. Indian J Pharmacol 2014;46:475-9.
] [Full text]
Alavi N, Nemati M, Kaviani M, Tabatabaii M. The effect of aromatherapy lavender on perception of pain labor intensity and outcome of delivery. Armaghan Danesh 2010;15:31-5.
Ozgoli G, Aryamanesh Z, Mojab F, Alavi Majd H. Study of inhalation of peppermint aroma on the pain and anxiety of the first stage of labor in nulliparous women: A randomized clinical trial. Qom Univ Med Sci J 2013;7:21-7.
Vakilian K, Keramat A. The effect of the breathing technique with and without aromatherapy on the length of the active phase and second stage of labor. Nurs Midwifery Stud 2013;1:115-9.
Hur MH, Oh HY, Park YS. Effects of aromatherapy on labor pain and perception of childbirth experience. Korean J Women Health Nurs 2005;11:135-41.
Herz RS. Aromatherapy facts and fictions: A scientific analysis of olfactory effects on mood, physiology and behavior. Int J Neurosci 2009;119:263-90.
Howard S, Hughes BM. Expectancies, not aroma, explain impact of lavender aromatherapy on psychophysiological indices of relaxation in young healthy women. Br J Health Psychol 2008;13:603-17.
Ali B, Al-Wabel NA, Shams S, Ahamad A, Khan SA, Anwar F. Essential oils used in aromatherapy: A systemic review. Asian Pac J Trop Biomed 2015;5:601-11.
Ocañez KL, McHugh RK, Otto MW. A meta-analytic review of the association between anxiety sensitivity and pain. Depress Anxiety 2010;27:760-7.
McKinney ES, Murray SS, James SR, Nelson K. Maternal-Child Nursing. 4th
ed.: Elsevier Health Sciences; 2013.
Vickers A, Stevensen C, Van Toller S. Massage and Aromatherapy: A Guide for Health Professionals. 1st
ed.: Springer; 1996.
[Table 1], [Table 2], [Table 3]
|This article has been cited by|
||New approaches to the effectiveness of inhalation aromatherapy in controlling painful conditions: A systematic review with meta-analysis
| ||Jessica C. Nascimento, Vitória S.S. Gonçalves, Bruna R.S. Souza, Laranda de C. Nascimento, Betina M.R. Carvalho, Patrícia K. Ziegelmann, Tiago C. Goes, Adriana G. Guimarães |
| ||Complementary Therapies in Clinical Practice. 2022; 49: 101628 |
|[Pubmed] | [DOI]|
||Frankincense diterpenes as a bio-source for drug discovery
| ||Hidayat Hussain, Luay Rashan, Uzma Hassan, Muzaffar Abbas, Faruck L. Hakkim, Ivan R. Green |
| ||Expert Opinion on Drug Discovery. 2022; : 1 |
|[Pubmed] | [DOI]|
||Pain management in the first stage of labour using sensory stimulation
| ||Surya Andina Mujiyani, Lutfatul Latifah |
| ||British Journal of Midwifery. 2022; 30(7): 396 |
|[Pubmed] | [DOI]|
||Labor Pain in Different Dilatations of the Cervix and Apgar Scores Affected by Aromatherapy: A Systematic Review and Meta-analysis
| ||Negin Shaterian,Reza Pakzad,Samaneh Dabbagh Fekri,Fatemeh Abdi,Negar Shaterian,Mina shojaee |
| ||Reproductive Sciences. 2021; |
|[Pubmed] | [DOI]|
||Nonpharmacologic approaches to pain management
| ||Prem Paul Nathenson, Sophie Nathenson |
| ||Nursing. 2021; 51(10): 62 |
|[Pubmed] | [DOI]|
||Aromatherapy intervention on anxiety and pain during first stage labour in nulliparous women: a systematic review and meta-analysis
| ||Ching-Chu Liao,Shao-Huan Lan,Yea-Yin Yen,Yen-Ping Hsieh,Shou-Jen Lan |
| ||Journal of Obstetrics and Gynaecology. 2020; : 1 |
|[Pubmed] | [DOI]|