Complementary Therapies in Clinical Practice 18 (2012) 66e70

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Episiotomy pain relief: Use of Lavender oil essence in primiparous Iranian women
Fatemeh Sheikhan a, *, Fereshteh Jahdi b, *, Effat Merghati Khoei c, Neda Shamsalizadeh d,
Masoumeh Sheikhan e, Hamid Haghani f
a

Islamic Azad University, Khalkhal Branch, Department of Midwifery, Khalkhal, Iran

Department of Midwifery, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
c
Department of Health, Tehran University of Medical Sciences, Tehran, Iran
d
Tehran University of Medical Sciences, Tehran, Iran
e
Bachelor Sciences of Computer, Tehran, Iran
f
Department of Statistics, Tehran University of Medical Sciences, Tehran, Iran
b

a b s t r a c t
Keywords:
Lavender
Povidoneeiodine
Episiotomy
Perineal care

Introduction: Post-episiotomy discomfort and its consequences can affect maternal quality of life and
mental health as well as the mother and baby relationship. Complementary medicine is increasingly
used and Lavender oil is frequently prescribed due to its antiseptic and healing properties.
Method: This clinical trial involved 60 qualied primiparous women admitted for labor in Kamali
Hospital in Karaj, Iran. They were randomly categorized into two groups: case (using Lavender oil) and
control (usual hospital protocol). Participants pain and discomfort were recorded using a Visual Analogue
Scale (VAS) and a Redness, Edema, Ecchymosis, Discharge Scale (REEDA). Pain was evaluated at 4 h, 12 h
and 5 days following episiotomy. Collected data was analyzed in SPSS 14 using an independent t-test and
chi-square.
Results: There was a statistical difference in pain intensity scores between the 2 groups after 4 h
(p 0.002, and 5 days (p 0.000) after episiotomy. However, differences in pain intensity between the
two groups, at 12 h post-surgery, were not signicant (p 0.066). The REEDA score was signicantly
lower in the experimental group (Lavender oil group) 5 days after episiotomy (p 0.000).
Conclusion: According to these ndings, use of Lavender oil essence can be effective in reducing perineal
discomfort following episiotomy. It is suggested that Lavender oil essence may be preferably to the use of
Betadine for episiotomy wound care.
2011 Elsevier Ltd. All rights reserved.

1. Introduction
Episiotomy is the most common perineal surgical incision in
obstetrical procedure. Approximately 33% of women with vaginal
deliveries received an episiotomy in 2000.1
However, the prevalence of episiotomy can vary between
countries. For instance, Asian races may be more prone to tearing
during delivery and so have higher than average routine episiotomy
rates.2
Mediolateral episiotomy rather than a midline episiotomy is
usually preferred because of the risk of the third or fourth degree
tear and where the perineum may be smaller as in Asian races.2,3
Like any other surgical incision, episiotomy results in some
discomfort for most postpartum patients.4 Studies have reported
that 10% of women experienced pain for more than two months

* Corresponding authors.
E-mail address: jahdi_fr@yahoo.com (F. Jahdi).
1744-3881/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctcp.2011.02.003

following spontaneous vaginal delivery with the rate rising to 30%

for those who had an assistant vaginal birth.5,6 In Iran the prevalence of mediolateral episiotomy (versus midline episiotomy) is
much higher than reported in the scientic literature. Thus it
seems logical to infer that the prevalence of surgical complications
may also be higher in Iranian women. One recent study revealed
that episiotomies were performed in 97.3% of 510 primiparous
women undergoing vaginal deliveries in Tehran.7 Since Episiotomies are similar to any other type of wound, care should be
afforded to healing these surgical incisions. At present, regular
antiseptic sitz baths are one of the methods for treating episiotomy
wounds.8
In Iran, povidoneeiodine is an antiseptic solution widely used
for surgical and skin wounds.9 Studies indicate that povidonee
iodine is not an effective solution and indeed, may inhibit wound
healing by causing skin reactions, allergic problems and irritations
that may impair wound healing.10
A study by Zahravi et al. suggested that there was no signicant
difference between betadine use and water in wound healing.11

F. Sheikhan et al. / Complementary Therapies in Clinical Practice 18 (2012) 66e70

67

3. Sample and setting

Cooper et al; also noted that povidoneeiodine with 1/20 of a typical

concentration can inhibit function of broblasts and lymphocytes.10
Despite this, oral analgesics and regular sitz baths using 10%
betadine for 30 min, are regularly used in Iran to heal Episiotomy
wounds. A randomized control trial involving 635 subjects evaluating the effectiveness of pain relief on perineal discomfort by
comparing pure Lavender oil, synthetic Lavender oil and an insert
substance as a bath additive for 10 days, again found no statistically
signicant difference between 3 groups. Although, those using
Lavender oil showed lower mean discomfort scores, particularly
between days 3 and 5.12 Vakilian et al. evaluated episiotomy healing
in 120 women for 10 days and suggested that there was no significant difference between two groups in pain intensity and healing
episiotomy. However, redness in the experimental group was
signicantly less than in the povidineeiodine group (p < 0.001).13
Nevertheless we were interested in exploring the use of
Lavender oil essence in perineal healing and pain relief in a group of
postpartum women from Iran. Recently, aromatherapy oil essences
have been founded to be effective in Obstetrics. Aromatherapy has
been used to facilitate healing and patient comfort in a range of
different ways.14e16
The oil essences derived from Lavender owers provide antibacterial, antifungal, carminative (relaxes smooth muscle), sedative, anti-depressive effects and can be effective for burns and
insert bites. A number of medical properties such as analgesic,
sedative, antispasmic and relaxing have been attributed to
Lavender oil.17,18 Lavandula angustifolia oil, like Linalyl acetate and
linalool, both in vitro and in vivo produced local anesthetic
activity.19 It has been suggested that this activity may be related to
the antimuscarinic activity or/and ion (Na/or Ca) channel
blockade.19,20 Lavender oil has an antinociptive effect and contains
aldehydes or phenols terpenes alcohols known for their antimicrobial activities.21 Moreover, Lavender oil is effective in the
treatment of antibiotic-resistant bacterial infections.22 This is
related to the antimicrobial activity of Lavender oil essence
compounds, including Cineole, Citral, Geraniol, Linalool, Menthol. A
major component of Lavender oil is Linalool, which has been shown
to initiate antibacterial activity against 17 of 18 bacteria (Grampositive bacteria and Gram-negative) and inhibit 10 of 12 fungi
(lamentous and non-lamentous).23 However, there is less
evidence addressing the effects of Lavender oil on wound healing in
many studies.24
Interestingly, little research has been conducted to evaluate the
effects of sitz baths and the application of Lavender oil essence as
an alternative way of treatment for reducing perineal discomfort.5
Maternal health after child birth directly affects a mothers
quality of life.25,26 This a reduction of episiotomy healing time may
well improve mothers quality of life during early mother-hood.3,27,28
Thus, nding new safe and effective way of wound healing was the
main goal of this study.
This study was performed to compare the effectiveness of
Lavender oil essence versus the routine practical program of sitz
bath with betadine.

The project was approved by the Ethics in Research Committee

of Iran University of medical sciences. The study was conducted in
the postpartum ward and clinic of Kamali Hospital in Karaj. Since
Betadine is used routinely in Iranian hospitals to improve the
healing of Episiotomy wounds, the control group used the routine
episiotomy treatment (Betadine sitz baths) provided by the
hospital); the experimental group used Lavender oil essence sitz
baths.
Between a period of four months (JulyeNovember 2009)
a convenience sample was identied comprising 60 primiparous
mothers with gestations terms between 37 and 42 weeks, cephalic
vaginal delivery. All were randomly allocated to either the experimental or control group. All the mothers had received an episiotomy and they were able to follow therapy guidelines.
The criteria for mothers to join the study were single tone
vaginal deliveries with episiotomy and without tearing; operative
delivery. Exclusion criteria were: systematic chronic diseases,
psychological problems, allergies, contextual diseases, eclampsia or
preclampsia during pregnancy, premature rupture of membranes
for more than 24 h, prolonged labor and precipitate labor, addiction, Volvo vaginitis or Hematoma in the perineum occurring up to
12 h post delivery. All participants voluntarily agreed to participate
in the study and signed an informed consent form. By using a table
of random numbers, the 60 subjects were randomly allocated to
one of two treatment groups. There was no difference between two
groups based on episiotomy wound, types of sutures or analgesic
dosage pre and post suture.
Subjects in the control group were asked to follow a usual
hospital routine programme of taking 30 min warm sitz baths
(10 ml Betadine 10% per 4 L water) twice each day for 5 days. The
experimental group received 30 min sitz baths (0.25 ml Lavender
oil essence per 5 L of water), twice a day for 5 days.
Episiotomy pain and discomfort were assessed by Visual
Analogue Scale and Redness, Edema, Ecchymosis, Discharge,
Approximation (REEDA) scales, respectively. Pain intensity and
discomfort assessments were completed before intervention and in
the rst 4 h following to provide a base line assessment of pain and
subsequent pain relief. Ratings were repeated at 4, 12 h and 5 days
post-episiotomy.
Episiotomy was also recorded using the REEDA scale 5 days
after episiotomy. All analgesics used by subjects were recorded.
Participants in both groups were routinely allowed to take
mefenamic acid capsules three times during the rst 12 h
following episiotomy and to take analgesics at home when
required. Where analgesic consumption appeared elevated,
subjects were excluded from the study. Individuals who failed to
attend for examination or presented with any signs of allergic
reaction or infection were similarly excluded from the study.
Data analysis was completed using SPSS software version 14.00
for Windows using T-test and x.2 The signicance level was set at
(a 0.005).

2. Methodology

4. Results

A randomized controlled clinical trial was conducted to evaluate

the effects of using Lavender oil to relieve episiotomy/perineal
discomfort in Iranian primiparous mothers. For the purposes of this
study, Lavender oil essence was extracted from fresh owers and
inorescences using the device Tkf500. Flowers were collected
before blooming and extracts provided by using hydro-distillation.
Bright yellow Lavender oil essence with a concentration of 0.96%;
Linalyl acetate 20% was extracted and made soluble in water at
18  C.

The results indicated that there was no signicant difference

between both groups in terms of demographic information such as
age, education, economical status, job experience. There were also
no signicant differences between obstetric and neonatal factors
including: length of episiotomy wound, duration of each labor stage
(rst to third), numbers of supercial stitches, mothers body mass
index 5 days post-episiotomy, neonatal head circumference or
commencement of breast feeding or re-commencing daily activities
after delivery (p > 0.005) (Table 1).

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F. Sheikhan et al. / Complementary Therapies in Clinical Practice 18 (2012) 66e70

Table 1
Demographic information, Obstetrical and neonatal and post partum factors
Variables (MeanSD)

Povidone-iodine
group (n 30)

Age
Duration of rst labor stage
Duration of second labor stage
Duration of third labor stage
Length of episiotomy
Number of supercial stitches
Neonatal head circumference
Body mass index

23.47
422.83
43.16
1.61
4.97
5
33.4
24.83

Education (diploma)
Economy status (moderate)
Job experience (householder)
Sitting status for breast feeding
Not start commencing daily activitie
5 days after delivery










4.14
75.33
5.33
0.42
0.32
0.26
1.37
1.55

lavender
group (n 30)
22.23
429.33
44.00
1.5
4.93
4.93
33.96
25.43










3.63
90.32
5.47
0.45
0.36
0.36
0.0004
1.19

p-value
0.46
0.2
0.21
0.45
0.5
0.46
0.38
0.31

Number %

Number %

p-value

11
23
30
26
30

15
26
30
23
29

0.74
0.43
0.36
0.62
0.09

36.7
76.7
100
86.7
100

50
86.7
100
76.7
96.7

There were no similarities noted between pain intensity noted.

The mean level for the intensity of the pain was (5.03  1.49) for
the Lavender oil group and (4.47  1.30) for control group; there
was no signicant difference between two groups (p 0.12) at this
point.
4.2. Pain score after intervention
After intervention the mean for pain intensity at 4 h post-op in
the experimental group was 2.7  1.74 and 4.23  1.59 in the
control group. This indicated a signicant difference between
groups (p 0.001).
Mean levels of pain intensity were (3.70  1.78) in the Lavender
oil users versus 4.53  1.56 in the control group 12 h following
episiotomy; however, this was not signicantly different between
two groups (p 0.06).
Mean levels of pain intensity for the experimental group was
2.43  1.94 versus 4.60  1.79 in the control group 5 days following
episiotomy (p 0.000). Moreover, 70% of subjects in the experimental group (Lavender oil group) had not taken analgesia in
contrast to 33.3% of participants in the control group who had not
consumed analgesics in the four days following their episiotomy.
This differential in analgesic use between the two groups was
signicant at (p 0.007).
There was a signicant difference between the mean level of
analgesics in 2,3,4 and 5 days after delivery (p < 0.05) (Table 2).
The mean and standard deviation for the REEDA scores before
intervention in each group were: (4.07  1.14) Lavender oil group;
(4.47  1.54), betadine group.
There was no signicant difference between two groups
(p 0.22).
There were no statistically signicant differences detected in
Redness, Edema, Ecchymosis, Discharge and Approximation
(REEDA) before intervention (Table 3).

day
day
day
day

2.07
2.03
1.97
1.93






1.66
1.67
1.7
1.7

Lavender oil group

Redness
Edema
Ecchymosis
Discharge
Approximation

1.37
1.2
0.4
0.07
1.00







0.76
0.48
0.6
0.25
0.00

Betadine group
1.43
1.30
0.67
0.03
1.03







0.77
0.59
1.02
0.18
0.18

p-value
0.25
0.27
0.68
0.58
0.16

The use of Lavender oil resulted in statistically signicant

differences detected by the REEDA score 5 days after episiotomy,
compared with Betadine use by the control group. There were no
differences detected in Discharge and Approximation between the
two groups. However the REEDA (Redness, Edema, Ecchymosis,
Discharge and Approximation) scale was signicantly lower in the
experimental group 5 days after episiotomy (p 0.000) (Table 4).

Lavender oil group

0.8
0.7
0.6
0.4






0.99
1.02
0.93
0.85

The mean difference is signicant at the 0.05 level.

Perineal pain commonly results from bruising of the perineum

followed episiotomy. Perineal trauma causes pain and discomfort
and this can dominate the initial experience of mother-hood.5,29 In
addition, pain may result in decreased mobility and discomfort
when passing urine or faeces. These issues can negatively impact
upon a womens ability to care for their newborn and carry out
daily activities.3,27,28 Furthermore, studies have shown that episiotomy healing versus spontaneous tearing may result in increased
chances of infection and can have negative effects on the womens
health in the postpartum period as well as negatively affecting
future sexual activity.25,26
Perineal pain in mediolateral and medial episiotomy tends to be
higher than with spontaneous tearing.30 Studies addressing episiotomy rates around the world indicate that this surgery ranges
from 9.7% between Northern Europe and Sweden to 96.2% between
South Africa to Ecuador. The lowest episiotomy rates appear to
occur in English-speaking countries (North AmericaeCanada:
23.8% and United States 32.7%) whilst remaining high in countries
such as South-America including Brazil: 94.2%, South Aferica-63.3%
and East Asia 82%.31
Recent studies in Greece revealed that greater numbers of
obstetricians prefer to do mediolateral and lateral episiotomies for
normal and operative vaginal birth.32 Given that there appears to
be higher levels of pain experienced by women who undergo
mediolateral episiotomies and that there is a high prevalence of
mediolateral episiotomy in Iran, it would seem particularly
important to address ways of relieving this type of pain.
Exploring the use of herbal essences is now receiving increased
attention in both midwifery and medicine.14,33
Linalyl acetate and linalool are compounds of oil essences that
can have sedative and local anesthetic effects.19,34,35 Linalool can
increase the local blood circulation and also reduces muscle tone
thus providing analgesic and sedative properties.17 Habananda

Table 4
Comparison of REEDA (Redness, Edema, Ecchymosis, Discharge and Approximation)
scales between experimental v control group: 5 days post-episiotomy.

Table 2
(mean  SD) level of analgesics consumption after delivery.

2
3
4
5

Variables (Mean  SD)

5. Discussion

4.1. Pain score before intervention

Control group

Table 3
Comparison of REEDA (Redness, Edema, Ecchymosis, Discharge and Approximation)
scales between control and experimental groups pre- intervention.

p-value
0.000
0.000
0.001
0.000

Variables (Mean  SD)

Lavender oil group

Redness
Edema
Ecchymosis
Discharge
Approximation
REEDA score

0.7
0.32
0.07
0.1
0.8
1.9








0.59
0.43
0.25
0.3
0.4
0.92

Betadine group
1.13
0.83
0.5
0.1
1.07
3.63








0.62
0.64
0.82
0.3
0.52
1.24

p-value
0.007
0.000
0.005
0.89
0.08
0.0000

F. Sheikhan et al. / Complementary Therapies in Clinical Practice 18 (2012) 66e70

reported that the effects of oil essence on limbic system leads to

endorphins, encephalin and serotonin release.36 Massage with
Lavender oil (L. angustifolia) for patients with chronic rheumatoid
arthritis similarly decreases pain, improves quality of sleep and
perceptions of well-being.20 Edwards et al. also demonstrated that
Lavender oil has antibacterial effects and can be effective in
prevention of infection and early repair of wounds.37
The composition of Lavender oil contains Alpha-terpineol and
terpinen-4-ol and camphor that have antibacterial effects. Alphapinene, beta-pinene and p-cymene are its other components that
have antifungal activity.17,38 Carvacrol, terpinen-4-ol, linalool,
sabinene, a-terpinene, and g-terpinene which are chemical
components in Lavendula stoechas have an antibacterial activity in
some Gram-negative and Gram-positive bacteria and an antifungal
activity in three pathogenic fungi.39,40 In addition P-cymene,
cryptone or thymol are known as potential inhibitor substances of
Pseudomonas aeruginosa growth.41 Similarly, caryophyllene oxide
which exists in Lavendula stoeches has anti-inammatory properties.42 Lavender oil essence from this plant provides antiinammatory properties by a variety of mechanisms including
endogenous glucocorticoid release, the effects of corticosteroid,
interactions with the biosynthesis of prostaglandins and interaction with tachykinin or other inammatory mediators.43
Our study suggests that the application of Lavender oil essence
on the perineum following episiotomy may be an effective form of
pain relief and enhance the wound healing process. Both groups
were in the hospital on the rst day after giving birth. In order to
monitor analgesic consumption and record pain intensity, all
subjects received routine hospital analgesia (Mefenamic Acid
250 mg every 8 h). In addition, it was viewed as ethical to ensure
subjects in both groups were able to take analgesia if they experienced pain. Both groups were provided with a form on which to
record their analgesia use. Analysis of analgesic consumption
showed that the experimental group reduced pain relief medication signicantly more than the control group. This reduction may
be due to the analgesic effects of Lavender oil essence.
Delays in perineal healing can result in an increase in complications including bleeding, infection, pain, urinary incontinence,
dyspareunia and the mothers anxiousness.44,45 In this study,
Lavender oil essences enhanced the healing process when
compared to the control group who used Betadine. In conclusion,
the inclusion of Lavender oil essence in warm baths can assist
episiotomy healing and reduce pain relief.
Further studies are recommended to explore this issue in more
detail.
Conict of interest statement
None declared.

Acknowledgment
Funds were provided for by the Iran University of Medical
Sciences. Additionally, this study would not have been possible
without the co-operation of all the clients who participated. The
assistance of Dr Reza Shams Ardakani, Dr Mahnaz Khanavi, is
gratefully acknowledged.

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