Comparing the Effects of Aromatherapy With Rose Oils and Warm Foot Bath on Anxiety in the First Stage of Labor in Nulliparous Women

Iran Red Crescent Med J.2014 September;16(9):e14455 D0:10.5812 ircmj..14455 Published online 2014 August 17. Research Article Comparing the Effects of Aromatherapy With Rose Oils and Warm Foot Bath on Anxiety in the First Stage of Labor in Nulliparous Women Masoomeh Kheirkhah";Nassimeh Setayesh Vali Pour";Leila Nisani';Hamid Haghani' Department of Midwifery,School of Nursing and Midwifery,Iran University of Medical Sciences,Tehran,IR Iran "Corresponding Authors:Nassimeh Setayesh Vali Pour,Deapartment of Midwifery,School of Nursing and Midwifery,Iran University of Medical Sciences,Tehran,IR Iran.Tel:+98- 9123660452,Fax:+98-2634530685,E-mail:setayesh_nassim64@yahoo.com;Masoomeh Kheirkhah,Deapartment of Midwifery,School of Nursing and Midwifery,Iran University of Medical Sciences,Tehran,IR Iran.Tel:+98-9123660452,Fax:+98-2634530685,E-mail:m-kheirkhah tums.ac.ir Received:August 27,2013;Revised:December 18,2013;Accepted:January 22,2014 Background:Anxiety is the most common emotional response in women during delivery,which can be accompanied with adverse effects on fetus and mother. Objectives:This study was conducted to compare the effects of aromatherapy with rose oil and warm foot bath on anxiety in the active phase of labor in nulliparous women in Tehran,Iran. Patients and Methods:This clinical trial study was performed after obtaining informed written consent on 120 primigravida women randomly assigned into three groups.The experimental group 1 received a 10-minute inhalation and footbath with oil rose.The experimental group 2 received a 10-minute warm water footbath.Both interventions were applied at the onset of active and transitional phases.Control group,received routine care in labor.Anxiety was assessed using visual analogous scale (VASA)at onset of active and transitional phases before and after the intervention.Statistical comparison was performed using SPSS software version 16 and P<0.05 was considered significant. Results:Anxiety scores in the intervention groups in active phase after intervention were significantly lower than the control group(P< 0.001).Anxiety scores before and after intervention in intervention groups in transitional phase was significantly lower than the control group(P<0.001). Conclusions:Using aromatherapy and footbath reduces anxiety in active phase in nulliparous women. Keywords:Aromatherapy;Warm Foot Bath;Anxiety;Active Phase;Nulliparous 1.Background Anxiety is the most common emotional response in Recently,complementary and attributable medicine women during delivery,which can be accompanied with CAM has been under investigation as a new obstetric adverse effects on fetus and mother(1).During labor and care for women during pregnancy and after delivery(7). childbirth,anxiety,fear,stress and pain is a continuous Aromatherapy is a kind of alternative medicine using es- chain and more anxious mothers need more sedatives sential oils and fragrant with stimulating the olfactory at different stages of labor(2).Anxiety is often involved system to induce relaxation and reduce anxiety(8). in pain,especially chronic pain,due to its progressive Although scientific studies have not shown its com- and gradual nature.When the pain becomes uncontrol- plete efficacy,it is believed that aromatherapy can act like lable,human coping skills are declined and anxiety in- medications on brain and nervous system.Aromathera- creases.Anxiety leads to feel intense pain and a vicious py decreases pain and induces relaxation by increasing cycle begins(3).Increased anxiety and pain improve cat- neurotransmitter and reduces epinephrine and nor- echolamine release and stimulation of alpha receptors epinephrine in the blood(9).The ester in oily essences by sympathetic nervous system,which in turn causes prevents muscle spasms,anxiety and depression (10). vasoconstriction,increased muscle tone and decreased Different methods of aromatherapy in labor such as in- uterine blood flow,increased blood pressure,loss of uter- halation,bath,footbath,and massage could be helpful ine contractions,slowing progression,and increased (8,11).Essential oils can be absorbed through the respi- metabolism and oxygen consumption in mothers (4). ratory system,leading to stimulation of the brain and Therefore,techniques to reduce anxiety would decrease relieving anxiety(12).Footbath is a common practice in both anxiety and pain.Special training in labor anxiety aromatherapy.Local heat therapies are generally safe and management is essential for maternity professionals considered as an effective form of complementary medi- especially midwives (5).Antianxiety agents have some cine.It basically means"as a tool to promote peace,create side effects including anesthesia and muscles relaxation, positive emotions,comfort,pleasure and fun to be part of headache(6). supportive care".Mechanisms responsible for the influ- Copyright @2014,Iranian Red Crescent Medical Joural;Published by Kowsar Corp.This is an open-access article distributed under the terms of the Creative Com- mons Attribution License,which permits unrestricted use,distribution,and reproduction in any medium,provided theoriginal work is properly cited

Iran Red Crescent Med J. 2014 September; 16(9): e14455. DOI: 10.5812/ircmj.14455 Published online 2014 August 17. Research Article Comparing the Effects of Aromatherapy With Rose Oils and Warm Foot Bath on Anxiety in the First Stage of Labor in Nulliparous Women Masoomeh Kheirkhah 1,*; Nassimeh Setayesh Vali Pour 1,*; Leila Nisani 1 ; Hamid Haghani 1 1 Department of Midwifery, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, IR Iran *Corresponding Authors: Nassimeh Setayesh Vali Pour, Deapartment of Midwifery, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, IR Iran. Tel: +98- 9123660452, Fax: +98-2634530685, E-mail: setayesh_nassim64@yahoo.com; Masoomeh Kheirkhah, Deapartment of Midwifery, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, IR Iran. Tel: +98-9123660452, Fax: +98-2634530685, E-mail: m-kheirkhah@tums.ac.ir Received: August 27, 2013; Revised: December 18, 2013; Accepted: January 22, 2014 Background: Anxiety is the most common emotional response in women during delivery, which can be accompanied with adverse effects on fetus and mother. Objectives: This study was conducted to compare the effects of aromatherapy with rose oil and warm foot bath on anxiety in the active phase of labor in nulliparous women in Tehran, Iran. Patients and Methods: This clinical trial study was performed after obtaining informed written consent on 120 primigravida women randomly assigned into three groups. The experimental group 1 received a 10-minute inhalation and footbath with oil rose. The experimental group 2 received a 10-minute warm water footbath. Both interventions were applied at the onset of active and transitional phases. Control group, received routine care in labor. Anxiety was assessed using visual analogous scale (VASA) at onset of active and transitional phases before and after the intervention. Statistical comparison was performed using SPSS software version 16 and P < 0.05 was considered significant. Results: Anxiety scores in the intervention groups in active phase after intervention were significantly lower than the control group (P < 0.001). Anxiety scores before and after intervention in intervention groups in transitional phase was significantly lower than the control group (P < 0.001). Conclusions: Using aromatherapy and footbath reduces anxiety in active phase in nulliparous women. Keywords:Aromatherapy; Warm Foot Bath; Anxiety; Active Phase; Nulliparous Copyright © 2014, Iranian Red Crescent Medical Journal; Published by Kowsar Corp. This is an open-access article distributed under the terms of the Creative Com￾mons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Background Anxiety is the most common emotional response in women during delivery, which can be accompanied with adverse effects on fetus and mother (1). During labor and childbirth, anxiety, fear, stress and pain is a continuous chain and more anxious mothers need more sedatives at different stages of labor (2). Anxiety is often involved in pain, especially chronic pain, due to its progressive and gradual nature. When the pain becomes uncontrol￾lable, human coping skills are declined and anxiety in￾creases. Anxiety leads to feel intense pain and a vicious cycle begins (3). Increased anxiety and pain improve cat￾echolamine release and stimulation of alpha receptors by sympathetic nervous system, which in turn causes vasoconstriction, increased muscle tone and decreased uterine blood flow, increased blood pressure, loss of uter￾ine contractions, slowing progression, and increased metabolism and oxygen consumption in mothers (4). Therefore, techniques to reduce anxiety would decrease both anxiety and pain. Special training in labor anxiety management is essential for maternity professionals, especially midwives (5). Antianxiety agents have some side effects including anesthesia and muscles relaxation, headache (6). Recently, complementary and attributable medicine CAM has been under investigation as a new obstetric care for women during pregnancy and after delivery (7). Aromatherapy is a kind of alternative medicine using es￾sential oils and fragrant with stimulating the olfactory system to induce relaxation and reduce anxiety (8). Although scientific studies have not shown its com￾plete efficacy, it is believed that aromatherapy can act like medications on brain and nervous system. Aromathera￾py decreases pain and induces relaxation by increasing neurotransmitter and reduces epinephrine and nor￾epinephrine in the blood (9). The ester in oily essences prevents muscle spasms, anxiety and depression (10). Different methods of aromatherapy in labor such as in￾halation, bath, footbath, and massage could be helpful (8, 11). Essential oils can be absorbed through the respi￾ratory system, leading to stimulation of the brain and relieving anxiety (12). Footbath is a common practice in aromatherapy. Local heat therapies are generally safe and considered as an effective form of complementary medi￾cine. It basically means "as a tool to promote peace, create positive emotions, comfort, pleasure and fun to be part of supportive care". Mechanisms responsible for the influ-

Kheirkhah M et al. ence of footbath are not yet fully clear,but soaking feet in asthma,allergies and skin disorders like eczema and any warm water to stimulate the sense of touch by massaging skin disorder were included.Exclusion criteria were all or washing can reduce sympathetic nerve activity,which mothers not in the natural course of labor who required its cause is not known,as the main mechanism is to in special care or emergency cesarean or had sensitivity to crease comfort to reduce pain(13).As an experimental the use of essential oils. care,footbath is applied by midwives in Japan during the To determine the sample size,the significance level of first stages of labor (14). alpha =0.05 and the test power of 80%were considered. One of the essential herbs used in aromatherapy is rose. Interventions were considered effective when anxiety Rose scent is effective on the central nervous system.Two scores reduced in the intervention groups than the con- materials,sytrinol and 2-phenyl ethyl alcohol,in roses are trol group(d =1.7).Based on similar studies,the standard known as antianxiety agents(15).Using oil rose reduces deviation in test and control groups were 3 and 2.2,re- anxiety by 71%in labor and only 14%of them need local an- spectively.Finally,34 samples were calculated;with as- esthesia (16).The difference in results of various studies suming a loss of 20%of the samples,the required sample is probably due to different techniques of aromatherapy size was determined 40. (2).In a review on the use of aromatherapy in childbirth, Finally,the study was conducted on 108 patients (36 Caroline and colleagues found different results and rec- patients in each group),and(36 controls).Four women ommended further researches(17).Using complemen- who received pethidine,three due to lack of cooperation tary and alternative medicine as a low-risk,cost-effective. in putting their legs in bath,one due to fetal heart rate easy and with limited side effects treatment in nursing below 100,one suspected abruption,one due to lack of and midwifery cares is growing in many medical centers. labor progression,and two without effective contraction Although some scientific evidences showed safety and ef- who received oxytocin were excluded from the study. ficacy of most CAM methods on people's health,proving Sampling was random assignment.For sampling,the the effectiveness and usefulness of this method of treat- first three eligible ones were given a closed envelope that ment requires further studies(18).Despite the acceptance was inside the nominal groups.First,one of the three en- of alternative medicine techniques,physicians rarely use velopes was returned.Second prize is one of the two re- CAM due to lack of adequate investigations(19).It is nec- maining envelopes were returned.Moreover,the last one essary to conduct more clinical studies to find safe and ef was back in the last pack.Sampling was performed in the fective psychotherapeutic approaches to reduce anxiety first three patients,respectively. and pain in labor. 2.Objectives ×(s1+s5 This study was conducted to compare the effects of aro- ax matherapy and rose oil and warm foot bath on anxiety in the active phase of labor in nulliparous women. Visual ruler to measure anxiety during labor(VASA)(Vi sual Analog Scale For anxiety)was used.The ruler has 10 3.Patients and Methods cm length,which zero at one end indicates "no anxiety" This randomized clinical trial study was conducted and number 10 represents the"greatest possible anxiety"; with two intervention groups and a control group in Ak- it possesses satisfactory reliability and validity based on bar Abadi hospital in Tehran,Iran in 2012.Akbar Abadi previous studies(20,21).Rose essential oil used in this Hospital is a governmental referral specialized hospital study was made by distillation of essential oils(Baryj for women. pharmaceutical Company,Iran)and licensed from the This research project was part of a thesis approved Ministry of Health building with the number of 4215. by the Research Council of Tehran University of Medi- Its active ingredients include sytrinol,geraniol,nerol, cal Sciences(Code;8743/250/DEJ90)and was approved linalool,and phenyl ethyl alcohol.In the first case,inha- by the ethics committee of Tehran University of Medi- lation and footbath with rose essential oil,rose essential cal Sciences,(code;90/D/130/2260 date 2012/2/18)and decrease of 1%,which was evaporated by Brenner room, registered in Iranian registry of clinical trials (code; for 10 minutes,she was breathing,simultaneously,a foot IRCT201112192751N4).The participants were given a full bath with rose essential oil with 1%water;40C for 10 explanation before sampling.Written informed consent minute was performed.In the second group,mothers was obtained from all participants.Patients were exclud- placed their feet for 10 minutes in a footbath containing ed at any time if were not willing to continue.Blindness 40C water.Interventions were performed once at the be. was not possible due to the nature of the intervention ginning of the active phase(cervical dilatation 4 cm)and in this study.The sample size was calculated as (power secondly at the beginning of the transition phase(8 cm 80%,exposure =20%,a=0/05)120 patients.Nulliparous dilation).The control group received routine care of the women with gestational age of 38-42 weeks,cephalic delivery room.Anxiety during pregnancy was measured presentation and 3 cm dilatation without a history of immediately before and after each intervention. Iran Red Crescent Med J.2014;16(9):e14455

Kheirkhah M et al. 2 Iran Red Crescent Med J. 2014;16(9):e14455 ence of footbath are not yet fully clear, but soaking feet in warm water to stimulate the sense of touch by massaging or washing can reduce sympathetic nerve activity, which its cause is not known, as the main mechanism is to in￾crease comfort to reduce pain (13). As an experimental care, footbath is applied by midwives in Japan during the first stages of labor (14). One of the essential herbs used in aromatherapy is rose. Rose scent is effective on the central nervous system. Two materials, sytrinol and 2-phenyl ethyl alcohol, in roses are known as antianxiety agents (15). Using oil rose reduces anxiety by 71% in labor and only 14% of them need local an￾esthesia (16). The difference in results of various studies is probably due to different techniques of aromatherapy (2). In a review on the use of aromatherapy in childbirth, Caroline and colleagues found different results and rec￾ommended further researches (17). Using complemen￾tary and alternative medicine as a low-risk, cost-effective, easy and with limited side effects treatment in nursing and midwifery cares is growing in many medical centers. Although some scientific evidences showed safety and ef￾ficacy of most CAM methods on people's health, proving the effectiveness and usefulness of this method of treat￾ment requires further studies (18). Despite the acceptance of alternative medicine techniques, physicians rarely use CAM due to lack of adequate investigations (19). It is nec￾essary to conduct more clinical studies to find safe and ef￾fective psychotherapeutic approaches to reduce anxiety and pain in labor. 2. Objectives This study was conducted to compare the effects of aro￾matherapy and rose oil and warm foot bath on anxiety in the active phase of labor in nulliparous women. 3. Patients and Methods This randomized clinical trial study was conducted with two intervention groups and a control group in Ak￾bar Abadi hospital in Tehran, Iran in 2012. Akbar Abadi Hospital is a governmental referral specialized hospital for women. This research project was part of a thesis approved by the Research Council of Tehran University of Medi￾cal Sciences (Code; 8743/250/DE/90) and was approved by the ethics committee of Tehran University of Medi￾cal Sciences, (code; 90/D/130/2260 date 2012/2/18) and registered in Iranian registry of clinical trials (code; IRCT201112192751N4). The participants were given a full explanation before sampling. Written informed consent was obtained from all participants. Patients were exclud￾ed at any time if were not willing to continue. Blindness was not possible due to the nature of the intervention in this study. The sample size was calculated as (power = 80%, exposure = 20%, α = 0/05) 120 patients. Nulliparous women with gestational age of 38-42 weeks, cephalic presentation and 3 cm dilatation without a history of asthma, allergies and skin disorders like eczema and any skin disorder were included. Exclusion criteria were all mothers not in the natural course of labor who required special care or emergency cesarean or had sensitivity to the use of essential oils. To determine the sample size, the significance level of alpha = 0.05 and the test power of 80% were considered. Interventions were considered effective when anxiety scores reduced in the intervention groups than the con￾trol group (d = 1.7). Based on similar studies, the standard deviation in test and control groups were 3 and 2.2, re￾spectively. Finally, 34 samples were calculated; with as￾suming a loss of 20% of the samples, the required sample size was determined 40. Finally, the study was conducted on 108 patients (36 patients in each group), and (36 controls). Four women who received pethidine, three due to lack of cooperation in putting their legs in bath, one due to fetal heart rate below 100, one suspected abruption, one due to lack of labor progression, and two without effective contraction who received oxytocin were excluded from the study. Sampling was random assignment. For sampling, the first three eligible ones were given a closed envelope that was inside the nominal groups. First, one of the three en￾velopes was returned. Second prize is one of the two re￾maining envelopes were returned. Moreover, the last one was back in the last pack. Sampling was performed in the first three patients, respectively. Visual ruler to measure anxiety during labor (VASA) (Vi￾sual Analog Scale For anxiety) was used. The ruler has 10 cm length, which zero at one end indicates "no anxiety" and number 10 represents the "greatest possible anxiety"; it possesses satisfactory reliability and validity based on previous studies (20, 21). Rose essential oil used in this study was made by distillation of essential oils (Baryj pharmaceutical Company, Iran) and licensed from the Ministry of Health building with the number of 4215. Its active ingredients include sytrinol, geraniol, nerol, linalool, and phenyl ethyl alcohol. In the first case, inha￾lation and footbath with rose essential oil, rose essential decrease of 1%, which was evaporated by Brenner room, for 10 minutes, she was breathing, simultaneously, a foot bath with rose essential oil with 1% water; 40 ° C for 10 minute was performed. In the second group, mothers placed their feet for 10 minutes in a footbath containing 40ºC water. Interventions were performed once at the be￾ginning of the active phase (cervical dilatation 4 cm) and secondly at the beginning of the transition phase (8 cm dilation). The control group received routine care of the delivery room. Anxiety during pregnancy was measured immediately before and after each intervention

Kheirkhah M et al. 3.1.Analysis 5.Discussion Statistical comparison was performed using SPSS soft- Severe maternal anxiety and fear of pain during child- ware version 16 and P<0.05 was considered significant birth cause cramps.Intense muscle contractions cause Chi-square test,ANOVAand Scheffe's test were performed. muscle hypoxia of the uterine muscle and interfere with uterine contractions and may actually interfere with the 4.Results delivery process. Anxiety scores in the three groups before the interven- Our results showed that anxiety in different phases of tion had no statistically significant difference at the be delivery after the intervention significantly reduced com- ginning of the active phase during labor(P=0.91).Anxi- pared to the control group(Tables 1 and 2).Anxiety score ety scores at the beginning of the active phase of labor after intervention was significantly different between the immediately after the intervention showed a statistically three groups at the beginning of the active phase.Anxiety significant difference between the three groups which was score in the first group was lower than other groups and significantly different(P=0.001).In the first group(inhala- in the second group was lower than the control group. tion and footbath with rose oil)anxiety score was 4 t2.31, This is inconsistent with the results of a study,which in the second group (warm footbath)5.53+1.98 and in con- showed no effect of essential oils on anxiety during labor trol group 7.61+2.06.Anxiety scores before the interven in the active phase(2).These differences can be due to the tion in transition phase during labor,in the first group was type of oil;also,their intervention was performed in the 3.69±2.4，second group531±2.56，and control group8.42 latent phase and massage style. +2.55.The statistically significant difference was found be- Anxiety scores before the beginning of the intervention tween anxiety score before the first group(P=0.001).How- in transition phase in the first group was lower than the ever,significant difference was not found between group other two groups.The reason can be due to the efficacy of 2 and group 3.Scheffe's test was used.Anxiety scores after rose essence during time.But Cook in a review article re- the intervention in transition phase in the first group was ported that essential oils caused an immediate decrease 2.25 +1.71,which is more effective than other groups and in- in anxiety(22).inhalation of Lavender essential oil im- tervention in the second group was more effective(4.67+ mediately after intervention reduced anxiety more effec- 2.74)than control group (8.28+2.26)(P=0.001). tively in primiparous women than 60 minutes after the Table1.Demographical Specifications of Research Subjectsa Groups Group1 Group2 Control X2Fb Pvalue Age,y 3.19±23.08 23.75±3.05 3.12±2.1 F=2.31 01 Education x×2=9.18 0.06 Under the Guidance 13(36.1) 12(33.3) 16(44.4) High School to Diploma 17(472) 18(48.2) 20(55.6) Collegiate 6(16.7） 7(19.4) 0(o) Occupation x2=5.8 0.08 Housewife 30(83.3) 29(80.6) 35(97.2) Employed 6(16.7) 7(19.4) 1(2.8) a data are presented as MeanSDand No.() D Chi-square. Table 2.Comparison of Anxiety Scores of Women in Labora Groups Group1,(N=36)Group 2,(N=36)Control,(N=36)PValue Before the Beginning of the Active Phase 7.28±176 725±2.27 7.44±1.91 0.91 After the Intervention in Active Phase 4±2.31 5.53±1.98 7.61±2.06 0.001b Before the Beginning of Intervention in the Transitional 3.69±2.4 531±2.56 8.42±2.55 0.001b Phase After the Beginning of Intervention in the Transitional 2.25±1.71 4.67±2.74 8.28±226 0.001b Phase a data are presented as Mean+SD. b Scheffe's test. Iran Red Crescent Med J.2014;16(9):e14455 3

Kheirkhah M et al. Iran Red Crescent Med J. 2014;16(9):e14455 3 3.1. Analysis Statistical comparison was performed using SPSS soft￾ware version 16 and P < 0.05 was considered significant. Chi-square test, ANOVA and Scheffe's test were performed. 4. Results Anxiety scores in the three groups before the interven￾tion had no statistically significant difference at the be￾ginning of the active phase during labor (P = 0.91). Anxi￾ety scores at the beginning of the active phase of labor immediately after the intervention showed a statistically significant difference between the three groups which was significantly different (P = 0.001). In the first group (inhala￾tion and footbath with rose oil) anxiety score was 4 ± 2.31, in the second group (warm footbath) 5.53 ± 1.98 and in con￾trol group 7.61 ± 2.06. Anxiety scores before the interven￾tion in transition phase during labor, in the first group was 3.69 ± 2.4, second group 5.31 ± 2.56, and control group 8.42 ± 2.55. The statistically significant difference was found be￾tween anxiety score before the first group (P = 0.001). How￾ever, significant difference was not found between group 2 and group 3. Scheffe's test was used. Anxiety scores after the intervention in transition phase in the first group was 2.25 ±1.71, which is more effective than other groups and in￾tervention in the second group was more effective (4.67 ± 2.74) than control group (8.28 ± 2.26) (P = 0.001). 5. Discussion Severe maternal anxiety and fear of pain during child￾birth cause cramps. Intense muscle contractions cause muscle hypoxia of the uterine muscle and interfere with uterine contractions and may actually interfere with the delivery process. Our results showed that anxiety in different phases of delivery after the intervention significantly reduced com￾pared to the control group (Tables 1 and 2). Anxiety score after intervention was significantly different between the three groups at the beginning of the active phase. Anxiety score in the first group was lower than other groups and in the second group was lower than the control group. This is inconsistent with the results of a study, which showed no effect of essential oils on anxiety during labor in the active phase (2). These differences can be due to the type of oil; also, their intervention was performed in the latent phase and massage style. Anxiety scores before the beginning of the intervention in transition phase in the first group was lower than the other two groups. The reason can be due to the efficacy of rose essence during time. But Cook in a review article re￾ported that essential oils caused an immediate decrease in anxiety (22). inhalation of Lavender essential oil im￾mediately after intervention reduced anxiety more effec￾tively in primiparous women than 60 minutes after the Table 1. Demographical Specifications of Research Subjects a Groups Group 1 Group 2 Control X2/F b P value Age, y 3.19±23.08 23.75 ± 3.05 3.12 ± 2.11 F = 2.31 0.1 Education x2 = 9.18 0.06 Under the Guidance 13 (36.1) 12 (33.3) 16 (44.4) High School to Diploma 17 (47.2) 18 (48.2) 20 (55.6) Collegiate 6 (16.7) 7 (19.4) 0 (0) Occupation x2 = 5.8 0.08 Housewife 30 (83.3) 29 (80.6) 35 (97.2) Employed 6 (16.7) 7 (19.4) 1 (2.8) a data are presented as Mean ± SD and No. (%). b Chi-square. Table 2. Comparison of Anxiety Scores of Women in Labor a Groups Group 1, (N = 36) Group 2, (N = 36) Control, (N = 36) P Value Before the Beginning of the Active Phase 7.28 ± 1.76 7.25 ± 2.27 7.44 ± 1.91 0.91 After the Intervention in Active Phase 4 ± 2.31 5.53 ± 1.98 7.61 ± 2.06 0.001b Before the Beginning of Intervention in the Transitional Phase 3.69 ± 2.4 5.31 ± 2.56 8.42 ± 2.55 0.001b After the Beginning of Intervention in the Transitional Phase 2.25 ±1.71 4.67 ± 2.74 8.28 ± 2.26 0.001b a data are presented as Mean ± SD. b Scheffe's test

Kheirkhah M et al. intervention (1).These are not consistent with the re- able and more satisfied.This method is recommended as sults of the study and indicate that rose oil has a chronic a complementary modality in supportive care as a low- effect to reduce anxiety.This lack of agreement is prob- risk,cheap and functional modality. ably due to differences in used oils.Anxiety scores after the first intervention decreased in intervention group Acknowledgements than the control group in transitional phase. The research group would like to thank the Research Saeki indicated that Lavender essential oil footbath for Department of Tehran University of Medical Sciences for 10 minutes led to a balance in autonomic nervous system financial support of the project.We also appreciate the activity and a feeling of comfort(22).They used essential collaboration provided by mothers and staff of Shahid oils with massage techniques to reduce stress and anxiety Akbar Abadi Hospital. during the latent phase of labor,but reported no effect of anxiety during labor,and even showed a significant Authors'Contributions increase in maternal anxiety score with advancing labor (2).The difference in results may be due to differences in Nassimeh setayesh vali pour participated in design,data the type of oil,type of intervention and delivery phase. collection,statistical analysis and drafting of the manu In the present study,anxiety scores during labor were script.Leila Neisani helped us in design and drafting of different in the three groups after intervention.After the the manuscript.Hamid Haghani helped us in statistical first intervention,in both intervention groups,anxiety analysis.Masoomeh Kheirkhah supervised the study.All was decreased.Consequently,most participants(31.6%)in authors read and approved the final manuscript. the first group had grades 6 to 8 of anxiety and (41.7%)in the second group,they had anxiety between 4 to 6.The References anxiety score after the first intervention was reduced Tafazzoli M,Zare mobini F,Mokhber N,Emami A.The effect of more in the second group,but with progression of labor, lavender oil inhalation on anxiety of the first stage of labor in anxiety is more,so anxiety scores during labor at the be- pregnant women first].Mental Health J.1389:1(49) 2. Hur MH,Cheong N,Yun H,Lee M,Song Y.[Effects of delivery nurs- ginning of the transition phase in the second group were ing care using essential oils on delivery stress response,anxiety in the range of 6 to 8,but in the first group it was in the during labor,and postpartum status anxiety].Taehan Kanho Hak- range of 4 to 6 and was reduced further compared to hoe Chi.2005357)H277-84. Golden WL,Dowd ET,Friedberg F.A modern approach. baseline score.This decrease was due to the use of rose Hypnotherapy.New York:Pergamon Press:1987. oil,thus rose oil requires little time to start its effect. Saisto T,Kaaja R,Ylikorkala O,Halmesmaki E.Reduced pain toler- Anxiety scores in transitional phase after the second in ance during and after pregnancy in women suffering from fear tervention in the first group reached the lowest level pos- of labor.Pain.2001:93(2)123-7. Bastard J,Tiran D.Aromatherapy and massage for antena sible,o to 2,but in the second group it remained in the tal anxiety:its effect on the fetus.Complement Ther Clin Pract. range of 6 to 8.This difference may indicate that reuse of 2006121:48-54. essential oils was more effective in transitional phase and Cunningham G,Kenneth I,Leveno S,Bloom J.Williams Obstetrics.New York:Mcgraw-Hill populations:2005. anxiety scores were more reduced.Besides,hot footbath Simbar M.Complementary therapies for pregnancy and child- was effective to reduce anxiety and prevent further anxi- birth.Healthy,community oriented..Tehran;1389. ety,but anxiety remains stable in the range of 6 to 8.It 8。 Steflitsch W,Steflitsch M.Clinical Aromatherapy:practicing medicine.jmh.2008;5(1):74-85. shows that warm footbath can reduce anxiety to a certain Kane A Childbirth and aromatherapy.Inter childbirth educat range,but one intervention is not enough.It could be the 12(1)H4-5. effect of the second intervention,which increased the 10. Strack M.Handbook of natural therapies,exploring the spiral of anxiety.Anxiety in the control group remained the most healing.CA:crossing press;1998. Beesley A,Hardcastle J,Hardcastle PT,Taylor CJ.Influence of pep- in all phases in the range of 8-10. permint oil on absorptive and secretory processes in rat small Via inhaling nice smells,the olfactory receptors con- intestine.Gut.199639(2):214-9. vey messages to the brain and affect memory,thought 12. Yamamoto K,Nagata S.Physiological and Psychological Evalua and emotion.Olfactory memory in response releases tion of the Wrapped Warm Footbath as a Complementary Nurs- ing Therapy to Induce Relaxation in Hospitalized Patients With neurotransmitter.Enkephalin reduces pain.Endorphins Incurable Cancer.Cancer Nurs J.2011:34(3)185-92. reduce anxiety and consciousness is associated with in- Miyazato K,Matsukawa K.Decreased cardiac parasympathetic creased release of noradrenalin(9).Aromatherapy with nerve activity of pregnant women during foot baths.Ipn Nurs Sci.2010,7165-75. rose oil and footbath can reduce anxiety by reducing 14. Umezu T,Ito H,Nagano K,Yamakoshi M,Oouchi H,Sakaniwa M, sympathetic stimulation. et al.Anticonflict effects of rose oil and identification of its active More investigations are needed to reach more accurate constituents.Life Sci.2002;72(1):91-102. conclusions about the effectiveness of aromatherapy in 5 Burns EE,Blamey C,Ersser Sl.Barnetson L,Lloyd Al.An investi- gation into the use of aromatherapy in intrapartum midwifery childbirth.The week point of this study was its non-blind- practice.[Altern Complement Med.2000;6(2):141-7. ness.Blindness was not possible due to the nature of the 16. Caroline AS,Carmel TC,Caroline AC.aromatherapy for pain man- intervention in this study. agement in labor.Cochrane Database OfSystematic Reviews.2011. Spencer W,Joseph I,Jacobs A Complementary and Alternative Overall,both interventions were effective to reduce Medicine.An Evidence-Base Approach.2008;20:33-5. anxiety of mothers and caused them to feel safe,comfort- Emslie M,Campbell M,Walker K.Complementary therapies in Iran Red Crescent Med J.2014;16(9):e14455

Kheirkhah M et al. 4 Iran Red Crescent Med J. 2014;16(9):e14455 intervention (1). These are not consistent with the re￾sults of the study and indicate that rose oil has a chronic effect to reduce anxiety. This lack of agreement is prob￾ably due to differences in used oils. Anxiety scores after the first intervention decreased in intervention group than the control group in transitional phase. Saeki indicated that Lavender essential oil footbath for 10 minutes led to a balance in autonomic nervous system activity and a feeling of comfort (22). They used essential oils with massage techniques to reduce stress and anxiety during the latent phase of labor, but reported no effect of anxiety during labor, and even showed a significant increase in maternal anxiety score with advancing labor (2). The difference in results may be due to differences in the type of oil, type of intervention and delivery phase. In the present study, anxiety scores during labor were different in the three groups after intervention. After the first intervention, in both intervention groups, anxiety was decreased. Consequently, most participants (31.6%) in the first group had grades 6 to 8 of anxiety and (41.7%) in the second group, they had anxiety between 4 to 6. The anxiety score after the first intervention was reduced more in the second group, but with progression of labor, anxiety is more, so anxiety scores during labor at the be￾ginning of the transition phase in the second group were in the range of 6 to 8, but in the first group it was in the range of 4 to 6 and was reduced further compared to baseline score. This decrease was due to the use of rose oil, thus rose oil requires little time to start its effect. Anxiety scores in transitional phase after the second in￾tervention in the first group reached the lowest level pos￾sible, 0 to 2, but in the second group it remained in the range of 6 to 8. This difference may indicate that reuse of essential oils was more effective in transitional phase and anxiety scores were more reduced. Besides, hot footbath was effective to reduce anxiety and prevent further anxi￾ety, but anxiety remains stable in the range of 6 to 8. It shows that warm footbath can reduce anxiety to a certain range, but one intervention is not enough. It could be the effect of the second intervention, which increased the anxiety. Anxiety in the control group remained the most in all phases in the range of 8-10. Via inhaling nice smells, the olfactory receptors con￾vey messages to the brain and affect memory, thought and emotion. Olfactory memory in response releases neurotransmitter. Enkephalin reduces pain. Endorphins reduce anxiety and consciousness is associated with in￾creased release of noradrenalin (9). Aromatherapy with rose oil and footbath can reduce anxiety by reducing sympathetic stimulation. More investigations are needed to reach more accurate conclusions about the effectiveness of aromatherapy in childbirth. The week point of this study was its non-blind￾ness. Blindness was not possible due to the nature of the intervention in this study. Overall, both interventions were effective to reduce anxiety of mothers and caused them to feel safe, comfort￾able and more satisfied. This method is recommended as a complementary modality in supportive care as a low￾risk, cheap and functional modality. Acknowledgements The research group would like to thank the Research Department of Tehran University of Medical Sciences for financial support of the project. We also appreciate the collaboration provided by mothers and staff of Shahid Akbar Abadi Hospital. Authors’ Contributions Nassimeh setayesh vali pour participated in design, data collection, statistical analysis and drafting of the manu￾script. Leila Neisani helped us in design and drafting of the manuscript. 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