[CG] Guideline for the use of aromatherapy for women in maternity services

Aromatherapy is the practice of using the natural oils extracted from flowers, barks, stems, leaves, roots and other parts of a plant to enhance psychological and physical well-being.

These essential oils are highly concentrated essences, with the chemical constituents believed to have a range of therapeutic properties.

The National Association of Holistic Aromatherapy define it  as the art and science of utilizing natural extracted aromatic essences to balance, harmonize, and promote the health of body mind and spirit. 

Often pregnancy carries the stigma of a no go zone for massage and aromatherapy treatments. According to the International Federation of Professional Aromatherapists (IFPA 2013) a pregnant client can greatly benefit from regular massages throughout the pregnancy period and essential oils can also help during labour and postnatal care.

• Aids relaxation and well-being, time for self
• Offers time to talk – to relieve anxieties, prevent depression, validate symptoms
• Eases physical discomforts of pregnancy
• Aids pain relief in labour
• Facilitates uterine action
• Assists adaptation to parenthood.
• Eases certain physical and psychological symptoms postnatally.

There was a large evaluative study on the use of aromatherapy in child birth with the objective being could this assist mothers coping mechanisms by improving wellbeing , reducing anxiety and fear and therefore influencing the perception of pain. 

• The use of essential oils was introduced to intrapartum midwifery practice at the Women’s Centre in Oxford in John Radcliffe Hospital in 1990
• This was an innovative approach to care and, consequently, the midwives in the delivery suite conducted a longitudinal research study between 1990 and 1998, with 8058 women taking part, to evaluate the effectiveness and safety of using essential oils during intrapartum care
• Midwives who were not Aromatherapists were trained by the principal of a local aromatherapy school to use ten selected essential oils for women in labour, to ease pain, relieve nausea and reduce anxiety
• The incidence of side effects was less than 1%, all of them minor, with none affecting the fetus or neonate
• This is the largest clinical trial on aromatherapy to date, and, although it was not randomised or double-lined study, it provides valuable evidence about aromatherapy practice. (Burns et al 1999).

The study clearly demonstrates that it is not necessary to obtain a full aromatherapy diploma in order to use a limited number of essential oils safely within intrapartum care.  It also demonstrated that essential oils can be administered to women with normal or complicated pregnancies, and has the potential to provide substantial benefits to women if used with care. 

Midwives can extend the scope of their clinical practice by undertaking appropriate training e.g. Denise Tiran’s 3 day training programme for midwives in the use of oils in the antenatal, intranatal and postnatal periods. With appropriate preparation, supervision and adherence to specifically developed guidelines, essential oil usage is a low-risk enterprise.

The midwife should keep up to date with knowledge and skills taking part in appropriate and regular learning and professional development activities that aim to maintain and develop their competence and improve their performance NMC “The Code” (Professional Standards 2015)

Midwives working within NHS acquire appropriate, adequate preparation in aromatherapy in order to extend their normal role in helping women in labour (Tiran and Mack, 2016). 

Midwives providing aromatherapy treatment, accept personal accountability for their practice (NMC 2015) 

Only midwives who have undertaken an appropriate training programme in aromatherapy, e.g

Diploma, Certificate or a specific 2 or 3 day programme developed for use in pregnancy (Denise Tiran) can develop and blend aromatherapy oils, documenting appropriately within the case record.

All other midwives can administer aromatherapy oils as directed by the qualified aromatherapist, appropriately documenting within the case record.

Midwives with the Diploma in Aromatherapy or equivalent are advisers regarding the use of essential oils.  They have a responsibility to keep the service safe and up to date and will be involved in evaluation of the service. They are committed to working collaboratively with midwifery and medical colleagues to provide integrated care.

Essential oils usage within the NHS Maternity services is constantly supervised and reviewed by the fully qualified Aromatherapists, enabling midwives to attain high standards and safe practice. In addition, the safety of mothers is protected within the NMC “The Code” (NMC, 2015).

• The Nursing and Midwifery Council (NMC2015) has included guidance for registrants in relation to the use of complementary and alternative therapies when used in conjunction with their work as a midwife, nurse or health visitor
• The use of natural remedies such as homeopathic medicines and aromatherapy essential oils, should only be used if it is in the best interest of the women, with her full knowledge and consent. If you believe that the use of these substances might not be in her best interest you have a duty to discuss this with the mother.
• The midwife practicing aromatherapy has a duty to practice in a competent, professional manner, to demonstrate evidence of continuing professional development and to work within boundaries of her/his professional role.

For insurance reasons, essential oils should be stored in a locked cupboard.  Only midwives who have attended the oil workshop should be collecting the oils from the cupboard and blending them. 

Women should be provided with sufficient knowledge to make an informed decision about the use of aromatherapy. Midwives offering essential oils are required to document the discussion together with rationale in the medical notes.  Discussion should include information about the essential oil(s) suggested and the reason for application and mode(s) of use.  Information should also be given on adverse associated symptoms.

There is a laminated chart available as a reference for the use of essential oils, which is provided to assist in the discussion and choice available for women prior to consent.  This is consistent with women being part of the decision-making process.

Verbal consent is sufficient and women should be aware that they have the opportunity to decline, without its affecting subsequent care as stated in the code of conduct (NMC, 2015).

Essential oils are available to women with or without complications in pregnancy labour or postnatally. Various inclusion and exclusion criteria have been put. In place and will be revised regularly

Inclusion criteria

• Women eligible for low risk care 
• Women who have given consent
• Women who are in the latent phase of labour; first, second or third stage of labour
• Women with spontaneous labour onset
• Women using birthing pool
• Women who are post-delivery whilst remaining in delivery/birthing suite

Confirmation of when to use essential oils

• Women may have repeated applications during labour of the same oils in same or different modes, as desired
• Women may use clary sage, rose and/or jasmine if being augmented in labour by ARM. However, administer the oils 30 minutes later following an obstetric intervention (such as an ARM or stretch and sweep) to avoid possible rapid labour (Burns et al, 1999)

Exclusion criteria

• Women who do not give consent
• Women outside the intrapartum/immediate postpartum period
• Professional doubt.

Contra-indications

• Clary sage, rose or jasmine should not be used for women who have had uterine surgery
• Clary sage, rose or jasmine should not be used for women in premature labour
• Peppermint or eucalyptus should not be given to women who are using homeopathic remedies as these two essential oils negate the effects of the remedies.
• Lavender should not be used for women with threatened pre-term labour, women who are hypotensive, or women that have hay fever or asthma triggered by pollen. May also have a sedative effect.
• Chamomile may be a skin irritant if used neat.
• Avoid massage directly over varicose veins
• Consider allergies when administering essential oils
• Citrus fruits avoid citrus oils
• Nuts – avoid carriers produced from nuts. ( grapeseed carrier of choice) Ø Gluten – avoid wheat germ oil Ø Hay fever – avoid floral oils.
• Do not use essential oils on babies
• Use caution when administering oils to women with severe asthma/respiratory problems
• Avoid hypotensive oils if diastolic blood pressure lower than 60 or if mother prone to postural hypotension or fainting in pregnancy
• Avoid abdominal massage if the placenta is situated on the anterior wall or history of antepartum haemorrhage or placenta praevia
• Avoid sedating oils like lavender, chamomile, ylang ylang after the administration of pethidine Ø Stop use if any adverse effects or labour proceeds to theatre delivery
• Midwives should administer no more than three essential oils per woman in labour. It is not advisable to use essential oils immediately following an intervention. For example, if an ARM and stretch and sweep have just been performed, delay the use of essential oils by about 30 minutes to avoid possible rapid labour (Burns et al, 1999).

Anti-depressant;   uplifting; produces a feeling of optimism; uterine tonic;

Physiological effects of constituents:

• Antispasmodic
• Analgesic
• Antibacterial, antifungal, antiviral
• Stimulating

Application to midwifery practice:

Pregnancy: (Near term) genital discharges (Lis-Balchin 1999), calming, relaxation, to boost self-confidence (Jelinek and Novokova 2001)

Labour: Emotionally warming and builds up confidence.  Used to reduce anxiety by decreasing the stress response from the hypothalamus (Stromkins 1998). Massage to abdomen/lower back can strengthen contractions and provide some pain relief, enhance uterine action (Fujiwara et al 2002), induction and acceleration of labour.  It may be useful to help expel placenta

Postnatal: After pains, depression.

Contraindications/Precautions:

• Contraindicated in pregnancy due to potential emmenagoguic action of cisjasmine and unknown effect on fetus (Stromkins 1998).
• Not to be given to women in threatened premature labour.
• Not to be given to women who have had previous uterine surgery.
• It is not advisable to use to assist contractions in birthing pool.
• Aroma may be overpowering, nauseating and may induce narcosis – consider effects on partner and midwife.

Good antidepressant; uterine tonic

Physiological effects of constituents:

• Mild anti-viral and bacterial properties.
• Mildly astringent
• Relaxing
• Soothing
• Balancing and uplifting.

Application to midwifery practice:

Pregnancy: Rose oil inspires emotional calm and stability without sedative effects.  Aroma is powerful and comforting.  Good relaxation effect.

Labour: Used for women with poor obstetric histories, depression, bereavement, anxiety and stress.  It has been helpful to assist contractions (Burns et al 2000).

Postnatal: Sensitive skin, pruritus, and eczematous conditions may benefit from this essential oil.

Contraindications/precautions:

• Not to be given to women in threatened premature labour.
• Not to be given to women who have had previous uterine surgery.
• It is not advisable to use to assist contractions in birthing pool.
• Pregnant midwives may wish to minimise contact.

Anti-inflammatory; powerful relaxant; sedating  

Physiological effects of constituents:

• Antiseptic, antibacterial, antifungal and antiviral (Schnaubelt 1998).
• Decongestant and expectorant Ø Calming (Holmes 1998; 1999).
• Mentally stimulating

Application to midwifery practice:

Pregnancy: Expectorant for colds, flu and sinus congestion, relaxation and balancing of emotions, frankincense vapours produces trihydro-cannabinole, a psychoactive substance to expand consciousness.

Labour: Useful in calming women who suffer from extreme panic and fear, anxiety, hyperventilation and insomnia..  It is often used to aid relaxation.  Pain relief, relief of anxiety and tension, balances emotions and eases fear.(Tiran 2016)

Postnatal: Depression and “Blues”.

Contraindications/precautions:

None.

Antibacterial, analgesic, uplifting, diuretic, healing

Physiological effects of constituents:

• Antibacterial
• Antifungal
• Uplifting
• diuretic

Application to midwifery practice:

Pregnancy: Relaxation, relieving anxiety, fear; varicosities, in compress; oedema

Labour:  Pain relief, reduction of fear and anxiety, calming

Postnatal:  Wound healing, baby blues, oedema, breast engorgement, nipple trauma

Contraindications/precautions:

• Caution with hypertensive women due to astringent effects
• Caution - use unadulterated oil only
• Contra-indicated in patients on Warfarin
• after severe blood loss

 Antispasmodic; immunostimulating; antiseptic; hypotensive

Physiological effects of constituents:

• Powerful astringent 
• Antiseptic
• Uplifting
• Hypotensive

Application to midwifery practice:

Pregnancy: Refreshing, cleansing, uplifting emotionally. The aroma of lemon is clarifying and can inspire increased concentration and awareness aiding the decision making process.  It replaces negative emotions by creating a cheerful atmosphere of freshness and purity.  It can help dispel mental fatigue and psychological heaviness.

Labour: There is anecdotal evidence that it can reduce hypertension for short periods. 

Postnatal: Combats symptoms of colds, catarrh, and throat infections.  Often used to enhance the effects of other essential oils.

Contraindications/precautions:

• Phototoxic oil, which can increase the skin’s sensitivity to ultraviolet light, causing accelerated burning and skin damage.
• May cause skin irritation and sensitivity in some.

Antibacteria; antispasmodic; diuretic  

Physiological effects of constituents:

• Mucus stimulant and expectorant
• Phlebotonic

Application to midwifery practice:

Pregnancy: Fluid retention, carpal tunnel, relaxing and calming towards term, suprapubic compresses for cystitis

Labour:                 

Postnatal: May reduce hair loss which occurs often in puerperium, haemorrhoids

Contraindications/precautions:

Astringent and phlebotonic properties suggest caution in hypertensive women

Relaxing; balancing; calming; sedating; analgesic; antiseptic

Physiological effects of constituents:

• Anti-infective
• Analgesic/anaesthetic
• Hypotensive
• Smooth muscle relaxant
• Anti-spasmodic through inhibition of both sympathetic and parasympathetic nervous systems
• Anti-inflammatory
• Carminative
• Expectorant

Application to midwifery practice:

Pregnancy: Stress, anxiety to aid relaxation.  Headaches, migraine, insomnia. Hypertension and pre-eclampsia (Louis and Kowalski 2002).  Cold and flu, sinus congestion. Backache, sciatica, symphysis pubis discomfort and other aches and pains.  Constipation, irritable bowel syndrome.

Labour: Pain relief, reduce anxiety, fear, tension, enhance uterine action; retained placenta (Burns et al 2000, Bowels 2002).  Increasing maternal coping capacity during childbirth; used to assist with contractions or to relax in the latent phase; mothers responded very positively when used in a perineal lavage following the birth.

Postnatal: Wound healing, reduce inflammation (Dale & Cornwall 1994).

Contraindications/precautions:

• Use with caution in early pregnancy due to presence of small amount of ketone (camphor and 1.8 cineole which can cause uterine bleeding (Tiran 2016)
• Avoid in mothers with hay fever or asthma triggered by flower pollen (Burns et al 2000).
• Caution with mothers prone to postural or severe supine hypotension also those with epidural anaesthesia due to potential to interact with bupivicaine (Tiran 2000).
• Caution with mothers undergoing induction or acceleration of labour due to possible effect on uterine tone (Tiran 2016).
• Beware sedative effect on midwives and other labour companion.

Relaxing; anti-inflammatory; anti-bacterial

Physiological effects of constituents:

• Antibacterial/anti-fungal.
• Anti-inflammatory.

Application to midwifery practice:

Pregnancy: Constipation, colic, diarrhoea, inflammation, leg cramps, painful joints due to ligament stretching.

Labour:  Relieves stress, anxiety.

Postnatal: Constipations, wound healing/cracked nipples.

Contraindications/precautions:

• May be an irritant if used neat in large doses.

Anti-emetic; analgesic; anti-inflammatory; revitalise; cooling effect

Physiological effects of constituents:

• Anti-emetic
• Analgesic
• Anti-inflammatory
• Uplifting/revitalises
• Cooling effect

Application to midwifery practice:

Pregnancy: Heartburn, indigestion, nausea, vomiting and constipation, headaches, stress and anxiety.

Labour: Pain relief, facilitation of uterine action, anxiety and heartburn.

Postnatal: Stress and anxiety.

Contraindications/precautions:

• Avoid in women with cardiac compromise as large amounts of menthol may trigger cardiac fibrillation.
• Avoid in epileptics.
• May be hepatotoxic and toxic to lungs due to menthofuran (metabolite of pulegone)
• Inactivates homeopathic remedies.
• May cause skin irritation if used neat in large doses.
• Stimulant effect can trigger sleep disturbance if used in large or continual doses.
• Theoretical possibility of potentiation of dermally –as menthol may increase permeability of stratum corneum, analgesic effects may be antagonised by concomitant use of eucalyptus oil.

Uplifting; analgesic; hypotensive

Physiological effects of constituents:

• Hypotensive.
• Antiseptic.
• Diuretic.
• Analgesic.
• Stimulant .

Application to midwifery practice:

Pregnancy: Nausea, anxiety, depression, constipation, stress and headaches.

Labour: Relieves fear and anxiety as it is an uplifting aroma.

Postnatal: Anti-infective, emotional calmer, uplifts to reduce baby blues.

Contraindications/precautions:

• Grapefruit is non-toxic/irritating/sensitising.
• Avoid in mothers who have an allergy to citrus fruit.

Powerful anti-inflammatory; analgesic; soothing/calming to emotions and for skin

Physiological effects of constituents:

• Antidepressant
• Antispasmodic
• Hypotensive
• Sedative
• Analgesic

Application to midwifery practice:

Labour: Relieves anxiety, uterine stimulant, relaxing/calming, can aid retained placenta, and reduces fear and tension.

Postnatal: Relieves varicose veins, constipation, relieves muscular aches and pains
and can reduce postnatal depression.

Contraindications/precautions:

• Avoid until near term due to emmenagoguic effects.
• Avoid use in women who have had previous uterine surgery.

Uplifting; balancing; relaxing

Physiological effects of constituents:

• Anti-depressant.
• Anti-septic.
• Hypotensive
• Sedative (nervous).
• Stimulant (circulatory).
• Aphrodisiac

Application to midwifery practice:

Pregnancy: General relaxation, calming, pre-eclampsia and anxiety.

Labour: Hypertension, stress and tachycardia.

Postnatal: Prevention and treatment of “baby blues” and depression.

Contraindications/precautions:

• Avoid prolonged use as aroma may be overpowering.

Antiseptic, Antibacterial qualities, relaxing uplifting, nausea vomiting, analgesia 

Physiological effects of constituents

• Relaxing
• Antiseptic
• Antibacterial
• Uplifting
• Aids nausea and vomiting

Application to midwifery practice:

Pregnancy: nausea, vomiting, relaxation, reduction of stress and anxiety, insomnia

Labour: relaxing, analgesic

Contraindications

• Not for use of persons with citrus allergies
• Increased risk of irritation to sensitive skin and photo toxicity

Antiviral; narcotic and sedative; anti-spasmodic

Physiological effects of constituents:

• Anti-viral.
• Narcotic.
• Sedative.
• Antispasmodic.
• Antidepressant.
• Aphrodisiac.

Application to midwifery practice:

Pregnancy: Anxiety, fear, depression, general relaxation; constipation and diarrhoea; cramps; insomnia; nausea

Labour: Generally uplifting, reduces anxiety; relieves nausea

Postnatal: Prevention and treatment of “baby blues” and depression.

Contraindications/precautions:

• None known, but beware effect on women prone to hay fever and asthma triggered by flower pollen and on those allergic to citrus fruit. (theoretical risk only)

Antiseptic; hypotensive; relaxing; analgesic

Physiological effects of constituents:

• Anti-viral.
• Antiseptic.
• Sedative.
• Antispasmodic.
• Antidepressant.
• Hypotensive.
• Analgesic

Application to midwifery practice:

Pregnancy: Relaxation, reduction of anxiety; calming and reduces blood pressure in pre-eclampsia; constipation, flatulence;colic; may relieve symptoms of urinary tract infection or cystitis

Labour: Analgesic, relief of spasm and fear, uplifting

Postnatal:

Contraindications/precautions:

• Photosensitive – caution due to melanocytic hormone in pregnancy – avoid exposure of skin in contact with bergamot to direct sunlight for up to 12 hours

 Antiseptic; antifungal; antibacterial; anti-inflammatory

Physiological effects of constituents:

• Anti-viral.
• Antiseptic.
• Antifungal.
• Antibacterial.
• Antimicrobial.
• Decongestant.
• Analgesic

Application to midwifery practice:

Pregnancy: Vaginal thrush, colds, influenza, supra-pubic compresses for relief of cystitis and urinary tract infection

Postnatal: Prevention and treatment of perineal or abdominal wound infection; via inhalation to treat respiratory tract infection

Contraindications/precautions:

• Do not use in labour – thought to relax myometrium, may theoretically reduce or stop contractions
• Possible dermatitis, especially with neat or prolonged administration to skin

Grapeseed oil is carrier oil used as a lubricant for smoothing essential oils into the skin.  It is fine, light oil which has no known contraindications and is hypoallergenic (Tiran 2016).

With maternal consent midwives are encouraged to perform simple tactile support using grapeseed carrier oil during any stage of labour.

Grapeseed oil may be with or without essential oils.

Birth partners may actively support women in labour through giving massage.

Storage: Oils must be stored on a locked cupboard within CMU.  Date of opening must be displayed on each oil bottle.

• Community midwives may blend oils for women to use in the home, but oils must not be made up in advance
• Essential oils should be kept in a locked case/cupboard at all times – there is greater potential for children to “play” with oils in the home setting
• Oil burners and aromatic diffusers may be used in the home, even though candle oil burners are prohibited in hospital due to oxygen outlets. However, keep oil burners away from Entonox apparatus and always ensure that oils burners are kept away from children and pets
• Citrus oils have a shelf life of 6-9 months and must be kept in a fridge. Grapeseed oil has a shelf life of 6 months
• Document use of essential oils in women’s notes
• Midwives should encourage women to use the communities own supply of essential oils in accordance with the guidelines, however, if the women wishes to use her own oils – it must be documented in the notes.

A treatment record sheet must be completed for all women receiving aromatherapy treatment and filled in the aromatherapy folder.

For each treatment there should be clear documentation of:

• Indication for treatment
• Essential oils used
• Carrier oil used
• Percentage blend
• Method of administration i.e. massage, compress, inhalation.

Indication for use of aromatherapy essential oil(s) and dosage, carrier oil and method of use should be clearly documented for each treatment on the reverse of the treatment record, and documented on badger system or patients handheld record. Only one treatment form is required for each patient and additional treatments should be added to the audit form. All documentation should be clear and concise and documented by the midwife administering treatment, in line with The Code (NMC 2015).

All adverse reactions must be clearly documented on the oil audit form.

In the unlikely event of a serious reaction, an incident form should be completed as part of the risk management process.

Essential oils must not be ingested.

Essential oils must not be used neat on the skin.

Care should be taken to avoid contact with sensitive areas such as face, eyes or nose.

Oils are flammable and should be kept away from flames.

Hands should be washed thoroughly after blending oils or giving a massage.

Oils should be stored in a locked cupboard

If a reaction occurs on the skin to an essential oil, apply plain carrier oil to dilute the oil, expose the skin to air to allow essential oil to evaporate, and wash skin with unperfumed soap to remove the oil.

If oil gets into the eye, flush the eye with saline eye wash, milk, or clean warm water.

(Tisserand and Young 2013)

If a serious reaction occurs seek medical help and report using the DATIX system and log in patient notes and aromatherapy audit.

Any unused massage oil containing essential oils should be soaked up in a tissue and disposed of in a sealed universal container in clinical waste bin. Any water containing essential oils should be disposed of in sluice.

Aromatherapy Audit Form (pdf)