A critical appraisal of the evidence pertaining to an aspect of midwifery practice that you have observed and/or practiced

von Baerbel Frodermann

The use of aromatherapy during childbirth: Is there evidence of the effectiveness of essential oils?

1. Introduction

The use of aromatherapy is one aspect of midwifery practice that has increased over the last few years (Enkin et al 2000). To use aromatherapy effectively, it is essential to understand the chemical composition, the way in which essential oils are absorbed, metabolised and excreted as well as potential side effects, contraindications and precautions (Tiran 2000).

This essay will explain how aromatherapy is used during childbirth, it will not discuss how aromatherapy is applied in pregnancy and in the postnatal period. Aromatherapy for women in childbirth was chosen as a topic for its recently increasing popularity in midwifery (Tiran 2000). It is also used in midwifery practice in the Delivery Suite of a large teaching hospital. The application of aromatherapy was observed by the author on one occasion, however, not in its use for childbirth but in the postnatal period. This concerned the use of camomile oil in a bath for a woman who suffered perineal discomfort postnatally.

The investigation of aromatherapy in midwifery practice offers the opportunity to analyse evidence of its use for childbearing women.
"As a practitioner responsible for his/her own practice, the midwife needs to make decisions about the care for mother and baby" and, thus, about what constitutes best evidence (Carnwell 2001, Greenhalgh 2001). The midwife is also obliged to provide the relevant information to the pregnant woman so that the woman can make an informed choice. The analysis of this topic further provides the opportunity for the author to develop the existing knowledge of aromatherapy as part of complementary therapies in midwifery.

Aromatherapy is defined as the application of essential oils to the improvement of physical and psychological well-being. Essential oils contain medicinal components that are extracted from natural sources like fruits, plants, herbs, barks and roots. Essential oils have diverse properties like, analgesic, antibiotic, antiseptic, expectorant and stimulate effects, to name but a few (Tiran 2000, Davis 1995).

2. Aromatherapy in childbirth: A literature review
There is limited research on the effects of essential oils in pregnancy, childbirth and the puerperium. This means that midwives can base their practice only on a limited body of knowledge (Tiran 2000). There are only a few empirical studies about aromatherapy in intrapartum care.

2.1 Predominant oils in childbirth
Within aromatherapy in childbirth a few essential oils are used frequently because of their effectiveness. These are: Lavender, frankincense, camomile, clary sage and peppermint (Tiran 2000).

2.1.1 Lavender (lavendula augustifolica)
Lavender has a broad range of properties like calming, nerve-strengthening, pain-relieving and antiseptic action (Tiran 2000). In childbirth, lavender is used for women with anxiety or stress to provide relaxation (Price and Price 1999, Dye 1992). At present, there is no evidence of its safety in pregnancy. Lavender is supplied in bath and massage (Tiran 2000).

2.1.2 Frankincense (boswellia thuriferia)
Frankicense oil has calminative, diuretic, uterine and antiseptic effects. It is used for women with high levels of anxiety, hyperventilation and hysteria during childbirth. The oil helps to slow down and deepen the breathing (Fawcett 1993). In the process of childbirth, this oil is used as a massage oil (Tiran 2000, Dye 1992).

2.1.3 Clary sage (Salvia sclarea)
Clary sage assists contractions and helps tone and stimulate the uterus (Burns et al 2000). It can be applied to induce labour or strengthen contractions during childbirth. It has euphoric properties (Guenier 1992). In addition, it has also antifungal, antiviral and antibacterial properties. For its analgesic properties it is good for women in labour (Tiran 2000). Clary sage oil should be avoided during pregnancy and it can even be toxic if applied in high dosage (Dye 1992, Fawcett 1993).

2.1.4 Peppermint (Mentha piperita)
Peppermint has antiseptic properties. It can be used for headaches, nausea and vomiting and also for pyrexia (Tiran 2000). This oil has cooling effects because it increases the topical blood circulation (Price and Price 1999). It should be applied through inhalation (Dye 1992, Fawcett 1993).

2.2 Methods of application of essential oils
Essential oils have been used for women in labour in combination with massage (Tiran 2000, Thourly and Rouse 1997). Other applications of essential oils are inhalations, compress, vaporizer, perineal lavage and bath (Tiran 2000). Aromatherapy is a safe, gentle and effective method of supporting women in childbirth (Mason 1996).

2.3 Effects of essential oils on women in childbirth
Research has shown that aromatherapy can help women to cope better both on a physical as well as emotional level with the pain and the process of labour (Moore and Holden 2000). In a major survey of 8,058 women in Delivery Suite of the John Radcliffe Hospital Oxford, 50% of mothers and midwives rated aromatherapy as helpful, 13% of mothers and 12% of midwives as unhelpful (Burns et al. 2000).

Potential side effects of aromatherapy in childbirth have been reported to include nausea and vomiting, rash and itching hayfever and watery eyes (Burns et al. 2000). However, the incidence of these symptoms are minimal, with 1% of a total of 8,058 survey women experiencing those (Ibid.).

In particular, aromatherapy in childbirth has been found to influence uterine action, fear and anxiety, pain relief and maternal well-being (Burns et al. 1999). These effects will be discussed in more detail in the following section.

2.3.1 Uterine action
Palmarosa, clove bud, fennel, peppermint, nutmeg, bay, aniseed, sweet thyme, lavender and jasmine have shown to exert uterotonic effects (Franchomme and Pénoel 1990). These oils can stimulate the action of the uterus and, therefore, support contractions (Tiran 2000). A longitudinal study of aromatherapy in childbirth provided strong evidence that essential oils augment labour contractions if women are in dysfunctional labour (Burns et al. 2000). The majority of these women, 86%, used clary sage oil (Ibid.). However progress of labour has also been found to be better in women who used a lavender oil bath when the cervix was 2 cms or more dilated (Norfolk and Reed 1993). The study were undertaken in Ipswich Hospital and the findings has to be viewed with caution because there were only 38 women involved.

2.3.2 Fear and maternal anxiety
Anxiety and fear are known to influence the levels of pain that women experience in labour (Telfer 1997). An authoritative longitudinal research of 8,058 women during the period of 1990 to 1998 has shown that lavender, yang yang and frankincense reduce fear and maternal anxiety (Burns et al. 2000). The study has shown that aromatherapy can be effective in reducing maternal anxiety. The results of the study are also valuable because of the duration and size. The use of essential oils was not confined to low-risk mothers.

2.3.3 Pain relief in labour
Aromatherapy can alleviate pain and discomfort in labour. The most commonly used oils in this context are lavender, jasmine, lemongrass and clary sage (Tiran 2000).
A smaller scale study of 38 women found that the majority rated a bath with lavender oil helpful for pain relief (Norfolk and Reed 1993). There is little published evidence that aromatherapy reduces the need for traditional pain relief. Further reasons were maternal dissatisfaction with the analgesic effects and higher awarness of mothers and midwives of the effects of analgesics on the baby (Burns et al 2000). Burns et al.'s (1999) research demonstrated that the use of pethidine in the study center declined from 6% to 0.2%.

2.3.4 Maternal well-being
Eucalyptus, mandarin and lemon oils have been found to improve overall maternal well-being (Burns et al. 2000, Tiran 2000). Anectodal evidence of a primigravidae who was admitted at Glasgow Southern Hospital and expected a long and painful labour suggests that aromatherapy increases maternal well-being (Reid 2001). The woman had a bath with essential oils when the contraction started. Her labour lasted eight hours and she had a drug free natural birth (Ibid.).

Further anecdotal evidence testifies towards improved levels of maternal well-being as a result of the use of aromatherapy in childbirth. Sylvia was 23 years old and a temperamental person who could not bear to be touched (Stadelmann 1992). A base oil of jojoba adding essences of rose , yang yang and clary sage were used for massage and, within minutes, was able to accept being touched and, thus, able to let the birth happen (Ibid.).

To support a childbearing woman effectively through aromatherapy, midwives need the ablility to explain the process and the method of its application to the woman in labour (Mason 1996).

2.3.5 Fetal well-being
A survey of 38 women in labour found that a bath with lavender oil increases fetal well-being. Research into pain relief for women in childbirth through the use of a bath based on five drops of lavender oil do not present any risk to the baby (Norfolk and Reed 1993).
The increased levels of fetal well-being identified in this research were measured using the Apgar score. However, the Apgar score is not alone a reliable measure of fetal well-being and the sample of this survey is small.

2.4 Reflections of Theory in Practice
The recurrent themes in the literature on aromatherapy in childbirth concern the types of oils being used, methods of application of aromatherapy, and effects on both the woman and the baby, issues of safety and risks.

The knowledge that was identified in the existing literature appears to be reflected in current midwifery practice. This judgement is based on the review of the guidelines and the author's conversations with midwives practising in the large teaching hospital. There, aromatherapy is used for women in established labour in both the latent and active phase. Essential oils are also applied in the 2nd and 3rd stage of labour. Aromatherapy is further used for women in spontaneous and induced labour, women who are preparing for elective or emergency Caesarean section. Women who use the birthing pool can also have aromatherapy.
However, midwives should only incorporate essential oils into care of the childbearing women, if they are qualified in aromatherapy (Tiran 2000). In Delivery Suite there are few midwives qualified in the administration of essential oils. Aromatherapy is given after consultation with one of the midwives who has been qualified in the field.

Based on this insight, it appears legitimate to suggest that in the context of the Delivery Suite of the teaching hospital the existing knowledge of aromatherapy in childbirth is well used. In the absence of further insight into practice, a more general evaluation of the theory-practice relationship cannot be given.

3. Conclusions
This essay has disscussed what aromatherapy is and how is it used for women in childbirth. The aim of this essay was to find evidence for the effectiveness and safety of essential oils to both childbearing women and their babies.

The existing understanding suggests that the use of essential oils in childbirth could be a valuable alternative for a more natural birth and that the integration of aromatherapy in childbirth could improve the quality of midwifery care (Burns et al. 1999). However, with the exception of the research of Burns et al. (1999), significant empirical evidence for the effects of aromatherapy and its methods of use is still widely lacking. The existing empirical research gives evidence that certain essential oils might be both safe and effective in childbirth, however, the results must be treated with caution and further research is needed to provide a firm and reliable basis for practice.

4. Future Research
As indicated above, aromatherapy appears to be a promising complementary method of care of women in childbirth. However, existing understanding in this particular field is too limited in terms of its lack of empirical evidence. Hence, future research would be valuable in all areas of aromatherapy discussed in this essay.

In particular, research into fetal well-being is of utmost importance, as the application of aromatherapy to the women in childbirth must reliably be safe for the baby. For example, Reed and Norfolk (1993) have started a line of research that should be pursued to establish more reliable evidence of the effect of lavender oil bath on the baby.

5. Learning from this Work
The analysis of the literature on the chosen topic was an extremely valuable experience
As an enthusiast of aromatherapy in general, this work has also shown me the fundamental importance of evidence-based working practices. Empirical research only is able to establish understanding of the potential consequences, positive and negative, of complementary methods both for childbearing women and their babies. I see that it is essential for safe, effective and responsible practice to constantly engage with the progress of empirical research.

Of course, this work offered also the opportunity to understand the state of existing knowledge in the use of aromatherapy in childbirth and to obtain the insight of how important it is to responsible practice to be selective and critical.

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