Archives of Gynecology and Obstetrics

https://doi.org/10.1007/s00404-018-4700-1

MATERNAL-FETAL MEDICINE

Efficacy of aromatherapy for reducing pain during labor: a randomized

controlled trial
Rajavadi Tanvisut1 · Kuntharee Traisrisilp1   · Theera Tongsong1

Received: 11 August 2017 / Accepted: 30 January 2018

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Background  Many strategies for labor pain management have been studied, including aromatherapy, which is a noninvasive,
alternative medicine used as an adjunct for labor pain control. Nevertheless, the results were contradictory. Therefore, we
conducted this study to determine the effectiveness of aromatherapy for reducing pain during labor.
Methods  A randomized controlled trial was carried out on Thai laboring primigravidae who were a low-risk singleton
pregnancy undergoing vaginal delivery. All participants, both study and control group, received standard obstetric care.
Aromatherapy was only provided to the study group during the first stage of labor. The women rated their pain intensity by
rating scales at different stages of labor. The primary outcome was pain scores and the secondary outcomes were necessity
of painkiller usage, labor time, aromatherapy-associated complications, route of delivery, and Apgar scores.
Results  A total of 104 women were recruited, 52 in each group. Baseline characteristics and baseline pain scores were
comparable. The median pain score of latent and early active phase was lower in the aromatherapy group, 5 vs 6 and 7 vs 8,
respectively. The mean differences of pain scores between latent and early active phase and the baseline were significantly
lower in the aromatherapy group, 1.88 vs 2.6 (p = 0.010) and 3.82 vs 4.39 (p = 0.031), respectively. Late active phase pain
scores and other perinatal outcomes were not significantly different.
Conclusion  Aromatherapy is helpful in reducing pain in latent and early active phase, and can probably be used as an adjunc-
tive method for labor pain control without serious side effects.

Keywords  Aromatherapy · Labor pain · Labor analgesia · Labor management

Introduction techniques. A commonly used method is intravenous pain-

Labor pain may be the most joyous pain in a woman’s
lifetime. However, labor pain, anxiety and stress during
hospital stay can lead to maternal discomfort, exhaustion
and possible unnecessary caesarean delivery. Proper pain
management is one of the goals to success and impressive
labor since both psychological response to pain and physi-
ological response such as hyperventilation, and increased
blood pressure can affect maternal/fetal wellbeing and labor
progression.
Many methods have been used for pain management dur-
ing labor, both pharmacological and non-pharmacological
* Kuntharee Traisrisilp
kuntharee.t@cmu.ac.th
1
Department of Obstetrics and Gynecology, Faculty
of Medicine, Chiang Mai University, Chiang Mai 50200,
Thailand
killers, such as meperidine, morphine or fentanyl. Such opi-
oids can possibly cause adverse neonatal outcomes, espe-
cially respiratory suppression. Moreover, the mothers may
take risk of aspiration, inadequate ventilation, dizziness,
nausea and over dosage [1]. Epidural analgesia is another
option for pain control used worldwide. However, it is not
available in most areas including our country. Though it is
highly effective for pain relief, epidural analgesia can result
in prolonged labor, more need of instrumental vaginal births
and cesarean section for fetal distress, higher risk of hypo-
tension, motor blockade, fever, urinary retention, and more
breast feeding problems [1]. Due to such side effects, many
pregnant women prefer suffering from labor pain instead of
receiving epidural analgesia for pain control.
Complementary and alternative medicine (CAM) for
labor analgesia has been more popular in the past decade,
for example hypnosis, massage, hot compression, breath-
ing exercise and aromatherapy [2, 3]. Aromatherapy is

13
Vol.:(0123456789)

“the science of using highly concentrated essential oils or
essences distilled from plants to utilize their therapeutic
properties”. In addition to the main purpose of pain relief,
aromatherapy is also used during labor for reducing anxi-
ety and fear [4]. For example, one large prospective cohort
study showed that more than 50% of 8058 mothers accepted
aromatherapy as a helpful option for pain relief during labor,
due to its noninvasiveness, ease of access and that it could
be an adjunctive choice for pain control [5]. Though many
studies have demonstrated the benefits of aromatherapy,
recent systematic reviews indicate that there is insufficient
evidence to support the effectiveness of aromatherapy in
pain management during labor [1, 6, 7]. This is mainly due
to a limited number of high-quality studies. To provide more
evidence-based data, we thus conducted this study aimed to
determine the effectiveness of aromatherapy via diffusion
in labor pain relief.
Materials and methods
The study was conducted at Maharaj Nakorn Chiang Mai
Hospital, Chiang Mai University, Thailand, between Decem-
ber 2015 and December 2016, with ethical approval by the
institutional review boards. Inclusion criteria were (1) sin-
gleton pregnancy, (2) primigravida, (3) term pregnancy (ges-
tational age between 37 and 41 weeks), (4) cephalic pres-
entation, and (5) spontaneous true labor, defined by regular
uterine contraction more than three times in 10 min with
cervical progression. Exclusion criteria were (1) obstetric or
medical complications of pregnancy that precluded vaginal
delivery, and (2) maternal smelling problems.
On admission, women going on labor and meeting the
inclusion criteria were recruited with written informed con-
sent. After enrollment, demographic and clinical data were
obtained. The participants were randomly assigned into two
groups: aromatherapy group and non-aromatherapy (con-
trol group), based on computer-generated randomization
using a block of four for allocation sequence of 1:1 ratio.
Sequentially numbered, sealed opaque envelopes were used
to provide allocation concealment. Aromatherapy group was
offered four options of the aroma favors to choose (lavender,
geranium rose, citrus and jasmine) based on their own pref-
erence, since the participants had best known what favor was
suitable for them in terms of personal odor satisfaction and
side effects such as nausea, vomiting, dizziness, etc. Other
labor standard care such as the intravenous fluid hydration,
uterotonic drugs, antibiotics, maternal/fetal monitoring were
provided to both groups as indicated. Additionally, analgesic
drug (meperidine) use was based on maternal request.
All women in the study group received the same pro-
cedure of aromatherapy. Aroma oil was diffused continu-
ously by aroma diffusers using standard concentration at
13
Archives of Gynecology and Obstetrics
four drops of aroma oil per 300 ml of diffused water. The
aromatherapy was started when the participants were admit-
ted for going on labor until the end of first stage of labor. The
Numerical rating scale from 0 (no pain) to 10 (worst possible
pain); NRS-11 was used for assessment of pain intensity.
The scale was explained by the physicians or nurses in the
research team to the participants before the therapy. Patients
rated their pain intensity by indicating a number which was
immediately recorded by the research team. Pain intensity
was evaluated at different stages of labor, including base-
line pain scores (pain scores on admission), latent phase
pain score (cervical dilatation of 3–4 cm), early active phase
pain score (cervical dilatation 5–7 cm), and late active phase
pain score (cervical dilatation 8–10 cm). Primary outcome
was early active phase pain scores. Secondary outcomes
included pain scores at the other stages of labor, dosage of
pain controller requested by the women, complications of
aromatherapy, labor augmentation, length of labor, route of
delivery and Apgar scores.
Sample size calculation was based on the difference
between early active phase pain score and baseline pain
score (primary outcome). A one-level of difference in
numerical rating scales between the two groups was selected
as the smallest effect that would be of clinical importance
[8]. With alpha value set at 0.05 (two-tailed) and the power
set at 90%, to express a significance of a small difference of
pain score if existing, the study needed a sample size of at
least 42 participants for each group.
Statistical analysis was performed using SPSS version
21.0 (released 2012; IBM SPSS Statistics for Windows, IBM
Corp., Armonk, NY, USA). Chi-square or Fisher’s exact test
was used to compare the categorical data between the two
groups. In comparison of the continuous data, student T test,
paired T test and Mann–Whitney U test were used as appro-
priate based on types of data and distribution. A p value of
less than 0.05 was considered as statistical significance.
Results
During the study period, 1695 women were admitted to
the delivery room at our hospital. A total of 106 women
met the inclusion criteria. Of them, two were excluded and
removed from the analysis because of incomplete data and
being transferred to another hospital before allocation. The
remainders were randomized into two groups, 52 of the con-
trol group and 52 of the aromatherapy group. All women
chose the type of aroma oil by their own preference (jasmine
n = 26, geranium rose n = 9, citrus n = 12 and lavender
n = 5), as presented in Fig. 1. About half of them (54%) were
employees and graduates with Bachelors’ degree. Most of
them had no known medical illness. Baseline characteristics
of both groups, such as maternal age, body weight, height,
Archives of Gynecology and Obstetrics

Fig. 1  Flowchart of the partici-

pant recruitment

body mass index and gestational age at delivery, were com- phase were significantly lower in aromatherapy group when
parable as shown in Table 1. compared to those of the control group (p < 0.001). Distri-
Baseline pain scores were similar in both groups (3, IQR bution of pain scores and interquartile ranges at different
2–5, p > 0.05). Pain scores during latent and early active stages of labor is presented in Table 2.

Table 1  Baseline characteristics Characteristics Aromatherapy (N = 52) Control (N = 52) p value*

of the aromatherapy and control
groups Age (SD), years 26.54 (4.692) 24.92 (4.315) 0.071
Body weight (SD), kg 67.96 (13.821) 64.60 (8.18) 0.135
Height (SD), cm 158.85 (5.37) 157.64 (5.56) 0.265
BMI (SD), kg/m2 21.31 (4.517) 21.06 (3.69) 0.762
Gestational age at delivery 38.08 (5.354) 38.77 (1.022) 0.362
(SD), weeks
Birth weight (SD), g 3186 (307.39) 3066.06 (254.22) 0.033

*Student’s T test

13
 Archives of Gynecology and Obstetrics

Table 2  Distribution of pain scores of the aromatherapy and control respectively). Finally, the number of cases requiring pain
groups control with meperidine was also not significantly different
Stage of pain Aromatherapy Control (75 vs 69.2%; p = 0.331). Of note, only one patient in the
Median (IQR) Median (IQR) aromatherapy group (1.92%) had nausea and vomiting dur-
ing aroma inhalation. Other serious complication caused by
Baseline 3 (2–5) 3 (2–5)
aromatherapy was not found.
Latent phase 5 (4–6) 6 (5–7)
Early active phase 7 (6–8) 8 (6–10)
Late active phase 10 (8–10) 10 (8–10)
Discussion

As labor progressed, women in the control group rated
their pain scores significantly higher than those in the aro-
matherapy group; latent phase pain 2.60 vs 1.88 (p = 0.010)
and early active phase pain 4.39 vs 3.82 (p = 0.031) in the
control and the study group respectively. Table 3 shows
absolute pain score changes from the baseline in each group
and the comparisons between both groups.
Route of delivery, the number of cases requiring labor
augmentation, length of labor and others of perinatal out-
comes were not significantly different between the two
groups. (Table 4) The rate of vaginal birth was not sig-
nificantly different between both groups (88.5 vs 78.8%;
p = 0.185). Likewise, the rates of operative vaginal delivery
and cesarean delivery were also not significantly different
(3.85 vs 9.62%; p = 0.240 and 7.69 vs 11.54%; p = 0.506,
This study supports that aromatherapy is helpful in reducing
labor pain in the latent phase and early active phase but it is
not effective in late labor when labor pain is more intense.
Because of the absence of serious side effects, it is prob-
ably reasonable to conclude that aromatherapy is helpful
alternative method for pain control, especially when used as
adjunctive care in early labor for women who want to avoid
pharmacological effect and regional analgesia.
Nowadays complementary and alternative medicine
(CAM) becomes more popular due to its noninvasive
method, ease to use, pharmacological avoidance and inex-
pensive care option, as shown by several studies that 20–60%
of pregnant women used CAM [9–11]. As already known,
many medications for pain control have side effects for both
mothers and fetuses, therefore alternative methods become

Table 3  Pain score changes Aromatherapy Control p ­value2

from baseline at various stages between
of labors Absolute change p ­value1 Absolute change p ­value1 group
(mean ± SD) within group (mean ± SD) within group

Latent phase 1.88 ± 2.24 < 0.001 2.60 ± 2.21 < 0.001 0.010*

Early active phase 3.82 ± 2.45 < 0.001 4.39 ± 2.10 < 0.001 0.031*
Late active phase 5.45 ± 2.28 < 0.001 5.62 ± 2.10 < 0.001 0.257
1
 Paired T test
2
 Mann–Whitney U test
*Statistically significant

Table 4  Comparisons of the perinatal outcomes between both groups

Outcomes Aromatherapy Control RR (95% CI) p value

Labor augmentation (intravenous infusion oxytocin) 28/52 (53.8%) 29/52 (55.8%) 0.96 (0.7–1.4) 0.844
Meperidine used 39/52 (75.0%) 36/52 (69.2%) 1.16 (0.73–1.83) 0.331
Mean length of first stage of labor (SD), min 775.6 ± 334.9 669.7 ± 463.7 – 0.205
Mean length of second stage of labor (SD), min 30.2 ± 28.1 23.6 ± 20.4 – 0.201
Admission to delivery time interval (SD), min 835 ± 368.9 750.9 ± 515.5 – 0.341
Spontaneous delivery 46/52 (88.5%) 41/52 (78.8%) 1.49 (0.76–2.93) 0.185
Operative vaginal delivery 2/52 (3.8%) 5/52 (9.6%) 0.55 (0.17–1.8) 0.240
Cesarean section 4/52 (7.7%) 6/52 (11.5%) 0.78 (0.36–1.7) 0.506
Apgar score at 1 min < 7 1/51 (2.0%) 2/52 (3.8%) 0.67 (0.13–3.3) 0.569
Apgar score at 5 min < 7 0/51 (0.0%) 0/52 (0.0%) – –

13
Archives of Gynecology and Obstetrics
an attractive choice since it can be an adjunct or even a
replacement of pharmacological treatment.
In this study, we used the aromatherapy aimed to decrease
pain intensity during labor process. Our results indicated
that pain score in the first stage of labor was significantly
reduced by aromatherapy, consistent with previous studies
[4, 5, 12, 13], although this was not confirmed in systemic
review [7]. Note that this study included only nulliparous
women. This is due to the fact that parity could be a con-
founding factor. Some studies reported that pain reduction
was only seen in nulliparous but not in multiparous women
[4], whereas some showed benefit in both nulliparous and
multiparous [5].
Our study found no significant difference in the rate of
maternal request for meperidine between both groups, con-
sistent with some previous reports [3, 7]. This finding sug-
gests that aromatherapy might not reduce the need of medi-
cations for pain relief or possibly the sample size was not
large enough to show a significant reduction with less extent.
However, some studies showed a significant reduction in the
need of pharmacological pain relief with aromatherapy [3,
5, 10]. Moreover, Dhany et al. [3] demonstrated a significant
reduction in the use of epidural anesthesia, spinal anesthesia
and general anesthesia with aromatherapy. To date, the effect
of aromatherapy on the need of pain relief medications is
inconclusive, though tends to be beneficial.
Fragrances of essential oils produce various positive
psychological effects such as reducing stress and enhancing
relaxation and alertness states of human brain function [14].
Burns et al. postulated that pain perception was reduced in
aromatherapy group [4]. Furthermore, the anxiety score
assessed during labor is also significantly reduced by aro-
matherapy [10, 15–17]. These may result in favorable labor
outcome because stressful condition might have the negative
effect such as heightening pain perception, delayed effective
labor, uteroplacental insufficiency, and fetal hypoxia [17,
18]. The effect of aromatherapy on labor course is inconclu-
sive. It may have the potential to augment labor contraction
[5, 18], significant effect on labor progress [19], a higher rate
of vaginal birth [4] and a lower incidence of operative deliv-
ery [10]. On the contrary, our study as well as some previous
studies [4, 7, 13] found no significant effect of aromatherapy
on labor augmentation. However, the different results may
be due to too small sample size for this secondary outcome.
Additionally, type of aroma might play a role. For example,
Kaviani et al. [20] found that Salvia could lower pain sever-
ity, shorten the first and second stage of labor than jasmine
could. Finally, our study showed no difference in Apgar
score at 1 and 5 min between the two groups, consistent
with previous studies [4, 5, 13].
Essential oil may irritate skin and mucous membrane
[18]. However, no report of associated adverse effects on
women [4]. Only 1% of 8058 mothers reported a mild related
symptom [5, 10]. Similarly, we found 1.92% had nausea,
occurring after the meperidine injection. Accordingly, it
could not be concluded whether the side effect was associ-
ated with aromatherapy or meperdine.
The strengths of this study are (1) randomization for
reducing selection bias, (2) adequate sample for evalua-
tion of the primary outcome, (3) using NRS-11 which has
standardized format, ease of use, good responsiveness and
good applicability [21], and (4) choosing aroma types by
the patient preference. The limitations of this study are (1)
no blindness of the treatment methods, (2) too small sample
size for evaluation of perinatal outcomes, (3) the results not
representing the effectiveness of aromatherapy in multipa-
rous women. This study included only nulliparous women
to avoid the potential confounder of parity, and finally (4)
this study included only one mode of aromatherapy, no
comparison between various techniques of aromatherapy
administration.
Based on this study and literature review, though some
contradictory results in some aspects, it is reasonable for us
to support the use of aromatherapy as an adjunct for labor
pain relief. Over half of mothers using aromatherapy rated
that it was useful during labor [5]. The majority of women
have a good experience about aromatherapy use, and they
would choose to use aromatherapy again in subsequent
labors, also would recommend it to friends [22]. For many
women, we suggest that pharmacological methods to soothe
the labor pain should only be used as a last resort.
Conclusion
Physicians can provide aromatherapy as an another option
for parturients because of its possible effectiveness for alle-
viating pain, simplicity to use, low cost, non-aggressive
method, no adverse effect and aiding relaxation. Finally, we
believe that this study add or accumulate high-quality evi-
dence to the sparse existing body of knowledge for a future
analysis.
Author contributions  TR: Protocol development, data collection,
administration of the project and manuscript writing. TK: Proposal
editing, data collection, data analysis and manuscript editing. TT: Data
analysis and final manuscript editing.
Funding  This study was funded by Faculty of Medicine Research
Fund, Chiang Mai University, Chiang Mai, Thailand. Grant Number
065/2559.
Compliance with ethical standards 
Conflict of interest  The authors declare no conflicts of interest.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
13
 Archives of Gynecology and Obstetrics

tional research committee and with the 1964 Helsinki Declaration and 11. Smith CA, Collins CT, Cyna AM, Crowther CA (2006) Comple-
its later amendments or comparable ethical standards. mentary and alternative therapies for pain management in labour.
Cochrane Database Syst Rev. https​://doi.org/10.1002/14651​858.
Informed consent  Informed consent was obtained from all individual CD003​521.pub2
participants included in the study. 12. Namazi M, Amir Ali AS, Mojab F, Talebi A, Alavi MH, Jannesari
S (2014) Effects of Citrus aurantium (bitter orange) on the sever-
ity of first-stage labor pain. Iran J Pharm Res 13:1011–1018
13. Yazdkhasti M, Pirak A (2016) The effect of aromatherapy with
References lavender essence on severity of labor pain and duration of labor
in primiparous women. Complement Ther Clin Pract 25:81–86
14. Diego MA, Jones NA, Field T, Hernandez-Reif M, Schanberg S,
1. Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn
Kuhn C, McAdam V, Galamaga R, Galamaga M (1998) Aroma-
M, Jordan S, Lavender T, Neilson JP (2012) Pain management for
therapy positively affects mood, EEG patterns of alertness and
women in labour: an overview of systematic reviews. Cochrane
math computations. Int J Neurosci 96:217–224
Database Syst Rev. https:​ //doi.org/10.1002/146518​ 58.CD0092​ 34.
15. Bishop K (2005) Aromatherapy: does it work? Ky Nurse 53:23
pub2
16. Rashidi-Fakari F, Tabatabaeichehr M, Mortazavi H (2015) The
2. Allaire AD, Moos MK, Wells SR (2000) Complementary and
effect of aromatherapy by essential oil of orange on anxiety dur-
alternative medicine in pregnancy: a survey of North Carolina
ing labor: a randomized clinical trial. Iran J Nurs Midwifery Res
certified nurse-midwives. Obstet Gynecol 95:19–23
20:661–664
3. Dhany AL, Mitchell T, Foy C (2012) Aromatherapy and massage
17. Rashidi FF, Tabatabaeichehr M, Kamali H, Rashidi FF, Naseri
intrapartum service impact on use of analgesia and anesthesia
M (2015) Effect of inhalation of aroma of geranium essence on
in women in labor: a retrospective case note analysis. J Altern
anxiety and physiological parameters during first stage of labor
Complement Med 18:932–938
in nulliparous women: a randomized clinical trial. J Caring Sci
4. Burns E, Zobbi V, Panzeri D, Oskrochi R, Regalia A (2007) Aro-
4:135–141
matherapy in childbirth: a pilot randomised controlled trial. BJOG
18. Tillett J, Ames D (2010) The uses of aromatherapy in women’s
114:838–844
health. J Perinat Neonatal Nurs 24:238–245
5. Burns EE, Blamey C, Ersser SJ, Barnetson L, Lloyd AJ (2000)
19. Hall HG, McKenna LG, Griffiths DL (2012) Midwives’ support
An investigation into the use of aromatherapy in intrapartum mid-
for complementary and alternative medicine: a literature review.
wifery practice. J Altern Complement Med 6:141–147
Women Birth 25:4–12
6. Arendt KW, Tessmer-Tuck JA (2013) Nonpharmacologic labor
20. Kaviani M, Maghbool S, Azima S, Tabaei MH (2014) Compari-
analgesia. Clin Perinatol 40:351–371
son of the effect of aromatherapy with Jasminum officinale and
7. Smith CA, Collins CT, Crowther CA (2011) Aromatherapy for
Salvia officinale on pain severity and labor outcome in nulliparous
pain management in labour. Cochrane Database Syst Rev. https​://
women. Iran J Nurs Midwifery Res 19:666–672
doi.org/10.1002/14651​858.CD009​215
21. Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW,
8. Jensen MP, Chen C, Brugger AM (2003) Interpretation of visual
Loge JH, Fainsinger R, Aass N, Kaasa S (2011) Studies compar-
analog scale ratings and change scores: a reanalysis of two clinical
ing Numerical Rating Scales, Verbal Rating Scales, and Visual
trials of postoperative pain. J Pain 4:407–414
Analogue Scales for assessment of pain intensity in adults: a sys-
9. Adams J, Lui CW, Sibbritt D, Broom A, Wardle J, Homer C, Beck
tematic literature review. J Pain Symptom Manag 41:1073–1093
S (2009) Women’s use of complementary and alternative medi-
22. Mousley S (2005) Audit of an aromatherapy service in a maternity
cine during pregnancy: a critical review of the literature. Birth
unit. Complement Ther Clin Pract 11:205–210
36:237–245
10. Burns E, Blamey C, Ersser SJ, Lloyd AJ, Barnetson L (2000)
The use of aromatherapy in intrapartum midwifery practice an
observational study. Complement Ther Nurs Midwifery 6:33–34

13