FeaturesClinical Aromatherapy for Pregnancy, Labor and Postpartum by Jane Buckle, PhD RN CCAP, Kathy Ryan, RNC-MNN CCAP and Karen B. Chin, RN MS CCAP Abstract: Clinical aromatherapy is the use of essential oils for clinical outcomes that are measurable, for example nausea, anxiety or pain. Essential oils are highly complex mixtures distilled from aromatic plants. They can be useful during pregnancy, labor, delivery, and postpartum. Essential oils can be applied in several different ways and are simple and pleasant to use. Essential oils are lipophilic (they do not dissolve in water). This paper will give an overview of published research relevant to maternal health, followed by examples of how aromatherapy is currently being used in a large maternity hospital, and give suggestions to encourage further integration. Keywords: aromatherapy, essential oils, labor, childbirth, postpartum Introduction Drawing on published research and clinical experience, clinical aromatherapy may be a potentially effective complementary practice in childbirth. This information will be useful for those who teach and care for the childbearing family. The aim is for clinical aromatherapy to become better understood as a potential tool for maternal health, thus making integration easier. Smell is one of the first senses to develop in the womb. Research has shown that babies can identify their mothers from smells first experienced in the womb (Faas, Resino, & Moya, 2011; Schaal, Marlier, & Soussignan, 2000). Odor has a direct pathway to the limbic part of the brain, in particular to the amygdala that governs fear (Buckle, 2007). Famil iar smells can be calming and soothing at stressful times (including childbirth), and some smells can have a profound psychological effect (Vermetten, Schmahl, Southwick, & Bremner, 2007). Most hospitals do not smell reassuring. Aromatherapy is the use of essential oils, obtained from aromatic plants, for therapeutic properties (Buckle, 2014, in press). Clinical aromatherapy is recognized as part of holistic nursing by the American Holistic Nurses Association and by most State Boards of Nursing (Buckle, 2003). Clinical aromatherapy is also used by doctors, massage therapists, nurse practitioners, occupational therapists, and many other healthcare workers (Cordell & Buckle, 2013). Essential oils can have many beneficial properties relevant to pregnancy, labor, delivery, and postpartum (Walls, 2009). For example, inhaling peppermint, spearmint, lavender, and ginger can relieve nausea (Reagan, 2009). Lavender, frankincense, and rose were found to relieve anxiety in labor (Burns, Zobbi, Panzeri, Oskrochi, & Regalia, 2007). German chamomile (Matricaria recutita) and Immortelle (Helicrysum italicum) have strong anti-inflammatory and healing actions. When diluted and applied topically, these two essential oils could be added to lavender (Lavandula angustifolia) - already found useful to aid perineal healing (Vakilian, Atarha, Bekhradi, & Chaman, 2011). Rose (Rosa damascena) and lavender (Lavandula angustifolia) relieved anxiety and depression in postpartum women (Conrad & Adams, 2012). Many essential oils, for example teatree (Melaleuca alternifolia), have antimicrobial properties, and these can reduce the possibility of Hospital Acquired Infections (HAIs) such as Methicillin Resistant Staphylococcus aureus (MRSA) or Acinetobacter baumannii (Duarte, Ferriera, Silva, & Dominigues, 2012; Warnke, Lott, Sherry, & Podschun, 2013). Aromatherapy is widely recognized as being useful in stress (Varney & Buckle, 2013), and clearly, labor is a stressful time for most women. Therefore it is not surprising that cur- continued on next page Volume 29 Number 4 October 2014 | International Journal of Childbirth Education | 21 Clinical Aromatherapy for Pregnancy, Labor and Postpartum continued from previous page rent reports suggest aromatherapy can reduce stress in pregnancy and childbirth (Conrad, 2010; Tillet & Ames, 2010). This article is supported with information from hospitals in Fort Worth, TX, Ridgewood, NJ, and Marshall, TX who use aromatherapy in their L & D departments. Published Evidence Aromatherapy for laboring mothers was introduced into a British hospital in the early 1990s by midwives Burns and Blamey (1994). Burns and Blamey�s initial six-month evaluation of aromatherapy on 500 laboring women in a maternity hospital in Oxford led the way to a much larger eight year study of 8,058 women (Burns, Blamey, Ersser, Barnetson, & Lloyd, 2000). The essential oils used were chamomile, clary sage, eucalyptus, frankincense, jasmine, lavender, lemon, mandarin, peppermint and rose (Burns et al., 2000). Women in labor were offered aromatherapy to relieve symptoms such as anxiety, pain, nausea, and vomiting or to help strengthen their contractions (Burns et al., 2000). Routine data were collected over eight years on the women who received aromatherapy and compared to the data on women who were not given aromatherapy (n = 15,799) (Burns et al., 2000). Outcome measures included mothers� ratings of effectiveness, outcomes of labor, use of pharmacologic pain relief, uptake of intravenous oxytocin, reported associated symptoms, and annual costs (Burns et al., 2000). More than 50% of mothers rated aromatherapy as helpful, and only 14% found it unhelpful (Burns et al., 2000). The use of aromatherapy was not confined to low-risk mothers - 60% were primigravidae, and 32% had induced labor (Burns et al., 2000). Aromatherapy appeared to reduce the need for Jasmine 22 | International Journal of Childbirth Education | Volume 29 Lavender additional pain relief, and the use of pethidine declined from 6% to 0.2% of women during the study (Burns et al., 2000). Aromatherapy also appeared to enhance labor contractions in women in dysfunctional labor (Burns et al., 2000). A very low number of associated adverse symptoms were reported (1%) (Burns et al., 2000). aromatherapy is a popular care option for mothers and midwives in many countries Rose A further study Burns, Zobbi, Panzeri, Oskrochi, and Regalia (2007) carried out in an Italian maternity unit found significantly more babies born to control participants were transferred to NICU than in the aromatherapy group: 0 versus 6 (2%, p = 0.017) (Burns et al., 2007). Pain perception was also reduced in the aromatherapy group for first time mothers (Burns et al., 2007). continued on next page Number 4 October 2014 Clinical Aromatherapy for Pregnancy, Labor and Postpartum continued from previous page Today, aromatherapy is a popular care option for mothers and midwives in many countries for myriad symptoms, such as nausea in pregnancy (and labor), hemorrhoids, exhaustion, pain, sleeplessness, anxiety, postpartum mood disorder, and episiotomy healing (Adams, 2012; Dhany, 2008; Maddocks-Jennings & Wilkinson, 2004; Tillet & Ames, 2010). A retrospective study by Dhany, Mitchell, and Foy (2012) explored if an aromatherapy and massage intrapartum service (AMIS) reduced the need for analgesia during labor. Seven essential oils were used: bergamot, clary sage, frankincense, lavender, jasmine, peppermint, and rose (Dhany et al., 2012). The essential oils were intended to target specific symptoms: symptoms requiring analgesia or antispasmodics; reduction of fear; mood elevating; calming; and enhancement of uterine action (Dhany et al., 2012). Some were also used to help to balance emotions, nausea, bereavement, and depression (Dhany et al., 2012). The analysis showed the AMIS had a positive impact and reduced the need for anesthesia during labor, thus contributing to improved maternal and neonatal outcomes (Dhany et al., 2012). Nausea There have been several published studies on aromatherapy for nausea. Most used peppermint (Hines, Steels, Change, & Gibbons, 2012; Reagan, King, & Clements, 2009), ginger (Boone & Shields, 2009; Ensiyeh & Sakineh, 2009), citrus peel (Stringer & Donald, 2011), or mixtures that included peppermint or ginger (de Pradier, 2006; Hunt, Dienemann, Norton, & Hartley, 2012). While most studies are on post-operative or chemo-induced nausea, studies have found inhaled essential oils useful for both early morning sickness and nausea in labor. However, an Iranian study found a �mint� essential oil (no botanical name given) floated in a bowl of water by the bed overnight did not reduce nausea the following morning (Pasha, Behmanesh, Mohsenzadeh, Hajahmadi, & Moghadamnia, 2010). Analgesia Maddocks-Jennings and Wilkinson (2004) found women who used a range of essential oils often required less analgesia. Kaviani, Azima, Alavi, and Tabaei (2014) found the effect of lavender reduced the perception of labor pain, and women�s self-evaluation showed them to be more content. However, there were no differences in the duration of the first or second stages of labor, nor was there a significant difference regarding the 1st and 5th minute Apgar score between the control and aromatherapy groups (Kaviani et al., 2014). Episiotomy Healing Vakilian et al. (2011) conducted a randomized control trial on 120 primiparous women with single pregnancy. The women in Vakilian et al.�s study had had normal spontaneous vaginal delivery and episiotomy and were not suffering from any acute or chronic disease or allergy. They were randomly allocated to the aromatherapy or control group (Vakilian et al., 2011). The aromatherapy group received lavender (Lavandula angustiolia) oil, and the controls received Povidoneiodine (Vakilian et al., 2011). Incision sites were assessed on the 10th day postpartum ( Vakilian et al., 2011). Vakilian et al. reported 25 out of 60 women in the lavender group reported no pain, whereas 17 mothers in the control group had no pain (p=0.06). Comfort Coleman Smith (2012) taught comfort methods using aromatherapy during childbirth classes to give the mother a sense of control during their labor. Coleman Smith suggested a foot soak of peppermint, a back massage with mandarin, rose, or ylang ylang, or a hand massage with eucalyptus. While aromatherapy can be of comfort in labor, having a doula who also has experience of using aromatherapy in labor can be very beneficial. Many cultures encourage continued on next page Volume 29 Number 4 October 2014 | International Journal of Childbirth Education | 23 Clinical Aromatherapy for Pregnancy, Labor and Postpartum continued from previous page women to have an experienced companion to encourage the mother and be pro-active in her comfort (Gruber, Cupito, & Dobson, 2013; Habanananda, 2004; Stevens, Dahlen, Peters, & Jackson, 2011). Labor and Delivery Rose (Rosa damascena) can be especially good in early labor when the woman may be more anxious. Rose can also help women sleep. Hongratanaworakit (2009) explored the effect of topically applied rose oil (Rosa damascena). When compared to placebo, rose oil reduced respiration rate, O2 saturation, and systolic blood pressure. Participants in the rose oil group rated themselves as more calm, more relaxed, and less alert than those in the control group (Hongratanaworakit, 2009). Jasmine, frankincense, and peppermint with back massage or compression to the forehead have been shown to be effective in active and transition (Coleman Smith, 2012; Pollard, 2008; Horowitz, 2011). Clary sage (Salvia sclarea) is thought to increase uterine contractility as well as acting as a stress reducer and anti-depressant (Coleman Smith, 2012). Postpartum Mood Disorder Imura, Misao, and Ushijima (2006) conducted a controlled study (n=26) to explore the use of aromatherapy massage on postpartum mood. The aromatherapy group received a mixture of neroli (Citrus aurantium flos) and lavender (Lavandula officinalis) in a massage on the second postpartum day, and the control group received standard medical care (Imura et al., 2006). Four standardized questionnaires were used before and after the intervention: Maternity Blues Scale, State-Trait Anxiety Inventory, Profile of Mood States, and Feeling Toward Baby Scale (Imura et al., 2006). In the aromatherapy group, post treatment scores significantly decreased for the Maternity Blues Scale (p=0.01), the State- Anxiety Inventory (p=0.001), and all but one of the Profile of Mood States subscales (Imura et al., 2006). Infertility Essential oils for infertility include ylang ylang, clary sage, geranium, fennel, anise, cypress, and rose. These oils decrease stress and anxiety and may aid in conception. Inhalation, topical application on the abdomen and low back, and massage may be beneficial (Tillett & Ames, 2010). Buckle has had some success regulating irregular periods that have contributed to infertility by using clary sage, geranium, and rose 10% applied to abdomen and back from the last day of period until ovulation. Using Clinical Aromatherapy in a Hospital Clinical aromatherapy was added to the RN�s toolkit of comfort measures for labor and postpartum at St.Vincent Women�s Hospital in Indianapolis, Indiana, five years ago. Today, every bedside RN has completed training (under direction of Kathy Ryan, RN CCAP) that enables them to offer six essential oils for inhalation only . A clinical aromatherapy policy was created to provide guidelines for the safe administration of essential oils in a clinical setting as a nursing intervention. This meant a physician order was not required to use aromatherapy. After seeing the benefits of clinical aromatherapy in action, the physicians became very supportive of offering aromatherapy. Patients are educated about the use of essential oils during childbirth preparation classes and during their preadmission Monogram Maternity appointment, where a birth plan is created. Fliers describing each oil and instructions for their use at home, are shared. Essential oils kits and resource materials are kept in each unit�s secured Medicine room. In order to address safety and infection control concerns, preparations for individual patient use are made up in the medicine room and then brought directly to the patient�s room in a labeled medicine cup. Medical history and allergies are reviewed before administering any essential oil. One to two drops are placed on a gauze square in a medicine cup, and safety precautions are emphasized with the patient before giving them the medi continued on next page 24 | International Journal of Childbirth Education | Volume 29 Number 4 October 2014 Clinical Aromatherapy for Pregnancy, Labor and Postpartum continued from previous page cine cup. Patient are instructed to close their eyes and take a long slow inhalation through their nose, repeating as needed. Nurses are trained to understand the contraindications and precautions of essential oils in this patient population. Patients are told not to apply undiluted essential oils directly to their skin; to only use them externally, avoiding the eyes; and to keep the medicine cup out of the reach of children. As an extra precaution, patients are advised to avoid inhaling essential oils during the first trimester of pregnancy, and nurses are told to observe this safety concern. Essential Oil Choices for Patients Essential oils offered (by inhalation only) are: � Lavender (Lavandula angustifolia) for relaxation and sleep � Bergamot (Citrus bergamia) for an uplifting and refreshing way to reduce stress � Ginger (Zingiber officinalis) to relieve nausea � Mandarin (Citrus reticulata) for a gentle, calming effect � Peppermint (Mentha pipertia) for nausea, headaches, fatigue and inability to void � Tea Tree (Melaleuca alternifolia) to relieve a stuffy nose and congestion. Patients are encouraged to use essential oils simultaneously with the Skylight guided imagery programs available through the hospital TV system. Lavender, mandarin, and peppermint are the essential oils most frequently chosen, and patients report success in relieving discomfort and decreasing their stress. Peppermint and ginger are available for use immediately after a cesarean section to relieve nausea and to lessen the potential use of antiemetic medications. The hospital has found that inhaling 1 � 2 drops of peppermint, ginger, or a blend of mandarin, peppermint, and ginger can relieve the discomfort of nausea during labor. Postpartum RNs frequently suggest the use of peppermint when a patient is unable to void. A drop of peppermint is placed on a tissue in the urine collection container while the patient holds the medicine cup under their nose, taking slow deep breaths of peppermint. With peppermint�s smooth muscle relaxation qualities, RNs report that it can be a successful strategy and is their first choice in this situation. This is interesting as a few drops of spirit of peppermint were placed in the urinary bottle if a male patient had problems RNs with advanced training in the safety and mixing of specific oils in small dilutions (often as low as 1%) have created favorite blends for use in Labor and Postpartum. These blends can be used in a massage lotion or oil, a soothing foot-bath, or drops in the shower for a refreshing scented steam. The ones most useful include: � Clary Sage, Roman Chamomile, and Lavender - While it has not been observed to be effective to initiate contractions, the nurses believe this blend may assist to increase the strength of existing contractions. Contraindications include a patient with a uterine scar, hyper stimulated contractions, or in conjunction with Pitocin or any other medication used to enhance labor. This is one blend that is discussed with the patient�s physician before use. Documentation of physician�s approval is placed in nursing notes for the use of Clary Sage during labor. � Lavender and peppermint blended with fractionated coconut oil and Epsom salts are added to warm water in a basin for a refreshing foot-bath. Care partners are encouraged to massage the patient�s feet at the same time. � A �Peace� blend containing Bergamot, Lavender and Mandarin in fractionated coconut oil can be calming, yet uplifting, during a long labor. � For those experiencing grief after a loss or an unexpected outcome, spritzers containing various combinations of Frankincense, Jasmine, Lavender, and Rose in a spray bottle of water are offered. This can be comforting while the patient is in the hospital, and their own spray is given to them for use after discharge. � Lavender and Roman Chamomile are mixed with a lotion and given to the Care Partners to use as a comforting rub during Labor. One patient wrote to thank her nurse stating: �The delivery made for a long day but the scent urinating, over forty years ago! continued on next page Volume 29 Number 4 October 2014 | International Journal of Childbirth Education | 25 Clinical Aromatherapy for Pregnancy, Labor and Postpartum continued from previous page of lavender and chamomile helped me relax and make it through! My mom and husband rubbed my back and neck to help take my mind off things and to help with the aches and pains of delivery! I use a little of the lotion now every night � it reminds me of the beautiful night my baby was born � scent is so tied to memory!� essential oils are complex � training is strongly recommended It is a privilege to be present when a baby is born. The goal of everyone present is to create a calm healing environment so mothers can have a best possible birth experience. Integrating clinical aromatherapy into maternal health care can enhance the experience and improve the comfort of laboring mothers, thus allowing them to focus on their goals for labor, for their baby, and for their immediate future together. The Importance of Training Essential oils are highly concentrated and some are contra-indicated in pregnancy and in labor (Tisserand & Young, 2013). It is strongly advised that those wanting to use aromatherapy in pre- and postpartum care learn how to use essential oils clinically. Training can be done easily by undertaking a clinical training that is specifically created for pregnancy and labor. This will enable the user to feel confident and comfortable about advising mothers what to use and what to avoid. Take Home Message Incorporating clinical aromatherapy into a childbirth care program enhances the comfort of laboring mothers and allows them to focus on their goals for labor � to produce a healthy, beautiful baby. However, essential oils are complex, concentrated extracts, and training is strongly recommended. References Adams, J. D. (2012). Massage and other CAM in pregnancy. International Journal of Childbirth Education, 27, 37-42. Boone, S., & Sheilds, K. (2005). Treatment of pregnancy-related nausea and vomiting with ginger. Annals of Pharmacotherapy, 39, 1710-1713. Buckle, J. (2003). Clinical aromatherapy: Essential oils in practice (2nd ed.). London, England: Churchill Livingstone. Buckle, J. (2007). Literature review: should nursing take aromatherapy more seriously? British Journal of Nursing, 16(2), 116-120. Buckle J. (2014, in press). Clinical Aromatherapy in Healthcare. London, England: Elsevier. Burns, E, & Blamey, C. (1994). Using aromatherapy in childbirth. Nursing Times, 90(9), 54-60. Burns, E. E., Blamey, C., Ersser, S. J., Barnetson, L., & Lloyd, A. J. (2000). An investigation into the use of aromatherapy in intrapartum midwifery practice. Journal of Alternative and Complementary Medicine, 6(2),141-147. Burns, E., Zobbi, V., Panzeri, D., Oskrochi, R., & Regalia, A. (2007). Aromatherapy in childbirth: A pilot randomized controlled trial. BJOG An International Journal of Obstetrics and Gynaecology, 114, 838-844. Coleman Smith, V. (2012). Aromatherapy as a comfort measure during the childbearing year. International Journal of Childbirth Education, 27, 26-30. Conrad, P. (2010). Aromatic childbirth: Developing a clinical aromatherapy maternity program. Beginnings, 30(4), 12-14. Conrad, P., & Adams, C. (2012). The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman - A pilot study. Complementary Therapies in Clinical Practice, 18(3), 164-168. Cordell, B., & Buckle, J. (2013). The effects of aromatherapy on nicotine craving on a U.S. campus: A small comparison study. Journal of Alternative and Complementary Medicine, 19(8), 709�713. de Pradier, E. (2006). A trial of a mixture of three essential oils in the treatment of postoperative nausea and vomiting. International Journal of Aromatherapy, 16(1), 15-20. Dhany, A. (2008). Essential oils and massage in intrapartum care. The Practising Midwife, 11(5), 34-39. Dhany, A. L., Mitchell, T., & Foy, C. (2012). Aromatherapy and massage intrapartum service impact on use of analgesia and anesthesia in women in labor: A retrospective case note analysis. Journal of Alternative and Complementary Medicine, 18(10), 932-938. http://dx.doi.org/10.1089/ acm.2011.0254 Duarte, M., Ferriera, S., Silva, F., & Dominigues, F. (2012). Synergistic effect of coriander oil and conventional antibiotics against Acitenobacter baumannii. Phytomedicine, 19(3), 236-238. Ensiyeh, J., & Sakineh, M. (2009). Comparing ginger and vitamin B6 for the treatment of nausea and vomiting in pregnancy: A randomized, controlled trial. Midwifery, 25(6), 649-653. Faas, A., Resino, C., & Moya, P. (2011). Neonatal responsiveness to the odor of amniotic fluid. Archives in Argent Pediatrics, 111(2), 105-109. Gruber, K., Cupito, S. J., & Dobson, C. F. (2013). Impact of douas on healthy birth outcomes. Journal of Perinatal Education, 22(1), 49-58. Habanananda T. (2004). Non-pharmacological pain relief in labor. Journal of the Medical Association of Thailand, 87(Suppl 3), S194-202. continued on next page 26 | International Journal of Childbirth Education | Volume 29 Number 4 October 2014 Clinical Aromatherapy for Pregnancy, Labor and Postpartum continued from previous page Hines, S., Steels, E., Change, A., & Gibbons, K. (2012). Aromatherapy for treatment of postoperative nausea and vomiting. Cochrane Database of Systematic Reviews, 2012(4), 1-52. http://dx.doi.org/10.1002/14651858. CD007598.pub2 Hongratanaworakit, T. (2009). Relaxing effect of rose oil on humans. Natural Product Communications, 4(2), 291-296. Hunt, R., Dienemann, J., Norton, J., & Hartley, W. (2012). Aromatherapy as treatment for postoperative nausea. A randomized trial. Anesthesia & Analgesia, 117(3), 597-604. Imura, M., Misao, H., & Ushijima, H. (2006). The psychological effects of aromatherapy-massage in healthy postpartum mothers. Journal of Midwifery & Women�s Health, 51, e21-e25. Kaviani, M., Azima, S., Alavi, N., & Tabaei, M. H. (2014). The effect of lavender aromatherapy on pain perception and intrapartum outcome in primiparous women. British Journal of Midwifery, 22, 125-128. Maddocks-Jennings, W., & Wilkinson, J. M. (2004). Aromatherapy practice in nursing: Literature review. Journal of Advanced Nursing, 48, 93-103. Pasha, H., Behmanesh, F., Mohsenzadeh, F., Hajahmadi, M., & Moghadamnia, A. A. (2012). Iranian Red Crescent Medical Journal, 14(11), 744-747. Reagan S. (2009). Quease ease aromatherapy for treatment of PONV. Presentation at the the American Association of Critical-Care Nurses Conference, Retrieved from http://www.nursinglibrary.org/vhl/handle/10755/157162 Schaal, B., Marlier, L., & Soussignan, R. (2000). Human fetuses learn odors from their pregnant mother�s diet. Chemical Senses, 20(3), 729-737. Stevens, J., Dahlen, H., Peters, K., & Jackson, D. (2013). Midwives� and doulas� perspectives of the role of the doula in Australia: A qualitative study. Midwifery, 27(4), 509-516. Stringer, J., & Donald, G. (2010). Aromasticks in cancer are: an innovation not to be sniffed at. Complementary Therapies in Clinical Practice, 17, 116-121. Tillett, J., & Ames, D. (2010). The uses of aromatherapy in women�s health. Journal of Perinatal and Neonatal Nursing, 24(3), 238-45. Tisserand, R., & Young, R. (2013). Essential oil safety. New York, NY: Churchill Livingstone. Vakilian, K., Atarha, M., Bekhradi. R., & Chaman, R. (2011). Healing advantages of lavender essential oil during episiotomy recovery: a clinical trial. Complementary Therapies in Clinical Practice, 17(1), 50-53 Varney, E., & Buckle, J. (2013). Effect of inhaled essential oils on mental exhaustion and moderate burnout: A small pilot study. Journal of Alternative and Complementary Medicine, 19(1), 69-71. Vermetten, E., Schmahl, C., Southwick, S., & Bremner, J. (2007). Positron tomographic emission study of olfactory induced emotional recall in veterans with and without combat-related stress disorder. Psychopharmacology Bulletin, 40(1), 8-30. Walls, D. (2009). Herbs and natural therapies for pregnancy, birth and breastfeeding. International Journal of Childbirth Education, 24, 29-37. Warnke, P., Lott, A., Sherry, E., & Podschun, R. (2013). The ongoing battle against multi-resistant strains: in vitro inhibition of hospital-acquired MRSA, VRE, Pseudomonas, ESBL, E coli and Klebsiella species in the presence of plant derived antiseptic oils. Journal of Cranio-Maxillofacial Surgery, 41(4), 321-326. Dr. Jane Buckle is the Director RJ Buckle Associates LLC www. rjbuckle.com and the author of Clinical Aromatherapy in Nursing (1997), Clinical Aromatherapy in Practice (2003) and Clinical Aromatherapy in Healthcare (due early 2015). In 1996, she created the first clinical aromatherapy program (CCAP) in USA. It was the first aromatherapy program to be endorsed by a national organization (The American Holistic Nurses Association) in 1999. She has trained over 3,000 nurses and doctors and now lives in London. Kathy Ryan, is the Clinical Coordinator of the Monogram Maternity Program at St. Vincent Women�s Hospital, Indianapolis, IN. Kathy has 37 years of experience in Maternal Child Nursing. Certificated in the �M� technique and as a CCAP (Certified Clinical Aromatherapy Professional), Kathy was instrumental in creating The St. Vincent Integrative Health Team. Karen B. Chin, RN, MS, CCAP is Adjunct Faculty, ADN Program at Panola College, in Panola St, Carthage, Texas. Karen�s ground- breaking, investigational study on the use of teatree (Melaleuca alternifolia in wound-healing was published in the Journal of Alternative & Complementary Medicine in 2013. She works a staff RN in PACU at the Good Shepherd Medical Center in Marshall, Texas. The focus of the next issue of the journal is �Fatherhood�. If you want to contribute, please send articles to
[email protected] by November 1, 2014. Publishing Assistance to ICEA Provided by Volume 29 Number 4 October 2014 | International Journal of Childbirth Education | 27 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Effectiveness of Aromatherapy Raju Janula1 and Singh Mahipal2 and Biofeedback in Promotion of Labour Outcome during 1 JJT University, Rajasthan, India 2 Akhil Bharati Vidyapeeth Nursing Childbirth among Primigravidas College, Sikar, Rajasthan, India Corresponding Author: Janula Raju .
[email protected] Abstract Research Scholar, Department of Nursing, JJT University, Rajasthan, India Background: Labour pain is the most severe form of pain that every woman may experience during intranatal life. Severe pain makes stress response which may lead to harmful effects on both mother and her fetus. This study was carried out Tel: +91 7415159891 to evaluate the effect of aromatherapy and biofeedback in promotion of labour outcome during childbirth among primigravidas. Methods: This clinical trial was performed on 600 nulliparous women selected randomly who were expected to have a normal childbirth. Cases were randomly assigned to Aromatherapy group (n=200), biofeedback group (n=200) groups and control group (n=200). The investigator rated the pain by using visual pain analog scale. Results: Sixty Nine percent (n=137) of cases in aroma massage group expressed it was helpful, provided pain relief and emotional wellbeing during labour. Our findings suggested, aromatherapy was helpful in reduction of duration of labour (p<0.0001). Biofeedback is also an effective in reducing pain and duration of labour during childbirth compared with the non-experimental group. Conclusion: The results of thispresent study indicated thatthe useofAromatherapy and Biofeedback were both effective methods of reducing pain perception and duration of labour among women during labor. Keywords: Aromatherapy; Biofeedback; Childbirth; Labour pain; Primigravida anxiety and fear are factors contributing towards women�s Introduction perception of pain and may also affect their labour and birth Childbirth is considered a life-changing event for most women experience. Pain associated with labour has been described as who are associated with great risks, and in certain cases it may one of the most intense forms of pain that can be experienced cause disability and even death for the mother or child [1]. [4]. Many women would like to avoid invasive methods of According to the World Bank report the maternal mortality pain management during labour and this may contribute to ratio in India was high as 200 maternal deaths per 100000 live the development of complementary or non-pharmacological births in 2013 [2]. Maternal mortality ratio (MMR) is defined methods for pain management. This study examined the use of as the death of a woman while pregnant or within 42 days of aromatherapy and biofeedback as non-pharmacological methods termination of pregnancy and is received by dividing the number for pain management in labour [5]. of maternal deaths per 100 000 live births.Women with adequate In aromatherapy therapy, essential oils from plants were psychological support and relaxation techniques had reduced the massaged in the skin, in a form of bath or inhalation using a incidence of caesarean section. Relaxation techniques, mainly steam or burner. Literature revealed that essential oils were used breathing exercises, had brought 50% reduction in caesarean to heal various ailments by therapeutically stimulating the nasal/ section for psychological indications [3]. olfactory senses (smell) via mental responses, circulatory and During labour conflicting emotions are present; fear and unease respiratory functions. Moreover it enhances physical and mental that can be coupled with anticipation and gladness. Tension, wellbeing of patients [6]. Biofeedback or biological feedback 2This article is available in: www.hsj.gr/archive ARCHIVOS DE MEDICINA ISSN 1698-9465 2015 Vol. 9 No. 1:9 Health Science Journal ISSN 1791- 809Xencompassesatherapeutictechniquewhereanindividualwillbetrainedtoimprovetheirown healthandwellbeingthroughsignalscomingfromthirownbodies(temperature,heartrate, musculartension,etc.) [7].Theunderlyingprincipleisthatchangesinthoughtsandemotionsmayresultinchangesinbod yfunctioning.Thepresentstudywascarriedouttocomparethereductionofpainanddurationofla bourbetweenthearomatherapytherapyandbiofeedbacktherapygropduringchildbirthamongprim igravidas. Method and Material ThedatacollectionwasdonefromDec2012toSep2013atselectedhospitalsinCoimbatoreDist,Tam ilNadu,SouthIndia. Inclusioncriteriacomprisedonlynulliparouswomen,withasingletonpregnancyofgestationag e>36weeks,singletonpregnancywithcephalicpresentation,cervicaldilatation=4cmandhavin gthreeuterinecontractionsin10minutesatleastwithadurationof30seconds.Exclusioncriter iaincluded,thirdtrimesterbleeding,intrauterinefetalgrowthretardation,multiplepregna ncy,breechpresentation,beingathletic,addiction(alcoholandcigarettes),usinganalgesic during3hoursbeforeandduringtheintervention,theuseofsedativedrugs,historyofinfertili ty, allergictolavenderoilduringskintest. Thiswasapost- testonlyexperimentalgroupdesign.Informationwasgatheredintheformofashortquestionnair etoelicitmaternalfeedbackaboutreceiving&administeringtheexperiment.Afterexplanation andobtainingwrittenconsentofwomen,theywererandomlyassignedtothreegroups: Group 1 Aromatherapy application Theoilusedforaromatherapywaslavenderoilandwasappliedbymassageduringlabourbytheinves tigator.Beforethetherapy, skinallergieswerecheckedbyconductingapatchtestontheskin.Randomlyselectedsubjects(n= 200)receivedaromatherapywhereoilwasappliedoverthebackandabdomenwithaslightmassage.T hemassagewascontinuedtilltheendoffirststageoflabour.8 ThepainwasassessedinLatentphase,activephaseandtransitionalphase.Routineintrapartumc arealsogivenforthemotherbythemidwives[9,10].Nofamilymemberswereinvolvedinthisstudy. Group 2 Biofeedback application Theinvestigatorpersonallyexplainedthepurposeofthestudywiththerandomlyselectedsubjec t(n=200).Cardiotokograph, anelectronicmachinewasusedforbiofeedbackstudy.Inthis, motheraskedtoexperiencebothfetalheartsoundandvariationinuterinecontractions.Ithelpe dhertoconsciouslyregulatebothpsychologicalandphysicalprocesses,suchaspain,whichwere notusuallyunderconsciouscontrol[5].ThepainwasassessedinLatentphase,activephaseandtr ansitionalphase.Theroutineintrapartumcarealsogivenforthemotherbythemidwives.Nofamil ymemberswereinvolvedinthisstudy.NeonataloutcomedataincludedAPGARscoresat1and5minute . Group 3 Control group (n=200) Receivedonlyroutineinterventionsaccordingtohospitalpolicies. Theroutinecarewasgivenbythemidwivesandtheinvestigatorhasrecordedthepainintensitylev elanddurationoflabouraslikeexperimentalgroup Ethical Considerations ThistrialwasapprovedbytheResearchEthicsCommittee(Protocolno:2013/PhDN/KG/006)ofconc ernedselectedhospitalinCoimbatore,India.Womencompletedinformedwrittenconsentform.Ea chwomanwasassignedanIDcode,ensuringdatasetanonymity.Womencouldwithdrawfromthestudya tanypoint. Limitations of the Study Thestudywaslimitedtoprimigravidamothersonlywithtwovariableslikepainanddurationoflab our.Thestudywasconductedinfewteachinghospitalsinthecity. Results Theresultsofthepresentstudyarebasedonthefindingsobtainedfromstatisticalanalysisofco llecteddata.Thewomenunderstudywereprimigravidas.Majorityofmothersunderstudywerehada gebetween21-25yrs(41%inaromatherapygroup, 48%inBiofeedbackgroupand46%inControlgroup).Mostofthemotherswerethehousewifeinallthr eegroups50%,53%and53%- aromatherapygroup,BiofeedbackgroupandControlgrouprespectively.Remainingmothersweret hecoolie,technicalandprofessionalworkers. Inthisstudythemeanpainscore(Table1)foraromatherapygroupandbiofeedbackwasreducedwhen comparedwithcontrolgroup.Similarlythemeanlengthofdurationoflabouralsoreducedinfirst stageandSecondstageoflabour(Table2). But�t�testdemonstratedthattherewasasignificantdifferencebetweenaromatherapyandbiofe edbackgroupinpainscore(Table3)duringlatentphase,activephaseandtransitionalphase. Whenconsideringthelengthoflabouritwasfoundsignificantdifferencebetweenaromatherapya ndbiofeedbackgroupinfirststageoflabour(p<0.0001).Butnodifference(Table4)werefoundin secondandthirdstageoflabour(p=0.0518,p=1.000respectively).Theassociationoffindingsw ithdemographicandobstetricalscorewasassessedbyusingchi- squaretest.Itwasreportedthatbodymassindex(.2=35.8),natureofonsetoflabourpain(.2=6.9 ),analgesics(.2=43.7),andhistoryofdysmenorrhea(.2=43.7)werehavingassociationwithlab ourpain(Table5).Butnatureofconception(.2=0.011)andregularantenatalcheckup(.2=3.15)i snothavingassociationwithlabourpain. Table 1 MeanandstandarddeviationofpainscoreTime of Assessment Aromatherapy Group Control group Biofeedback Group Mean SD Mean SD Mean SD Latentphase6.20.138.60.57.80.15Activephase7.50.219.00.348.2 0.19Transitionalphase8.30.479.60.219.20.01 This article is available in: www.hsj.gr/archive ARCHIVOS DE MEDICINA ISSN 1698-9465 2015 Vol. 9 No. 1:9 Health Science Journal ISSN 1791- 809Xencompassesatherapeutictechniquewhereanindividualwillbetrainedtoimprovetheirown healthandwellbeingthroughsignalscomingfromthirownbodies(temperature,heartrate, musculartension,etc.) [7].Theunderlyingprincipleisthatchangesinthoughtsandemotionsmayresultinchangesinbod yfunctioning.Thepresentstudywascarriedouttocomparethereductionofpainanddurationofla bourbetweenthearomatherapytherapyandbiofeedbacktherapygropduringchildbirthamongprim igravidas. Method and Material ThedatacollectionwasdonefromDec2012toSep2013atselectedhospitalsinCoimbatoreDist,Tam ilNadu,SouthIndia. Inclusioncriteriacomprisedonlynulliparouswomen,withasingletonpregnancyofgestationag e>36weeks,singletonpregnancywithcephalicpresentation,cervicaldilatation=4cmandhavin gthreeuterinecontractionsin10minutesatleastwithadurationof30seconds.Exclusioncriter iaincluded,thirdtrimesterbleeding,intrauterinefetalgrowthretardation,multiplepregna ncy,breechpresentation,beingathletic,addiction(alcoholandcigarettes),usinganalgesic during3hoursbeforeandduringtheintervention,theuseofsedativedrugs,historyofinfertili ty, allergictolavenderoilduringskintest. Thiswasapost- testonlyexperimentalgroupdesign.Informationwasgatheredintheformofashortquestionnair etoelicitmaternalfeedbackaboutreceiving&administeringtheexperiment.Afterexplanation andobtainingwrittenconsentofwomen,theywererandomlyassignedtothreegroups: Group 1 Aromatherapy application Theoilusedforaromatherapywaslavenderoilandwasappliedbymassageduringlabourbytheinves tigator.Beforethetherapy, skinallergieswerecheckedbyconductingapatchtestontheskin.Randomlyselectedsubjects(n= 200)receivedaromatherapywhereoilwasappliedoverthebackandabdomenwithaslightmassage.T hemassagewascontinuedtilltheendoffirststageoflabour.8 ThepainwasassessedinLatentphase,activephaseandtransitionalphase.Routineintrapartumc arealsogivenforthemotherbythemidwives[9,10].Nofamilymemberswereinvolvedinthisstudy. Group 2 Biofeedback application Theinvestigatorpersonallyexplainedthepurposeofthestudywiththerandomlyselectedsubjec t(n=200).Cardiotokograph, anelectronicmachinewasusedforbiofeedbackstudy.Inthis, motheraskedtoexperiencebothfetalheartsoundandvariationinuterinecontractions.Ithelpe dhertoconsciouslyregulatebothpsychologicalandphysicalprocesses,suchaspain,whichwere notusuallyunderconsciouscontrol[5].ThepainwasassessedinLatentphase,activephaseandtr ansitionalphase.Theroutineintrapartumcarealsogivenforthemotherbythemidwives.Nofamil ymemberswereinvolvedinthisstudy.NeonataloutcomedataincludedAPGARscoresat1and5minute . Group 3 Control group (n=200) Receivedonlyroutineinterventionsaccordingtohospitalpolicies. Theroutinecarewasgivenbythemidwivesandtheinvestigatorhasrecordedthepainintensitylev elanddurationoflabouraslikeexperimentalgroup Ethical Considerations ThistrialwasapprovedbytheResearchEthicsCommittee(Protocolno:2013/PhDN/KG/006)ofconc ernedselectedhospitalinCoimbatore,India.Womencompletedinformedwrittenconsentform.Ea chwomanwasassignedanIDcode,ensuringdatasetanonymity.Womencouldwithdrawfromthestudya tanypoint. Limitations of the Study Thestudywaslimitedtoprimigravidamothersonlywithtwovariableslikepainanddurationoflab our.Thestudywasconductedinfewteachinghospitalsinthecity. Results Theresultsofthepresentstudyarebasedonthefindingsobtainedfromstatisticalanalysisofco llecteddata.Thewomenunderstudywereprimigravidas.Majorityofmothersunderstudywerehada gebetween21-25yrs(41%inaromatherapygroup, 48%inBiofeedbackgroupand46%inControlgroup).Mostofthemotherswerethehousewifeinallthr eegroups50%,53%and53%- aromatherapygroup,BiofeedbackgroupandControlgrouprespectively.Remainingmothersweret hecoolie,technicalandprofessionalworkers. Inthisstudythemeanpainscore(Table1)foraromatherapygroupandbiofeedbackwasreducedwhen comparedwithcontrolgroup.Similarlythemeanlengthofdurationoflabouralsoreducedinfirst stageandSecondstageoflabour(Table2). But�t�testdemonstratedthattherewasasignificantdifferencebetweenaromatherapyandbiofe edbackgroupinpainscore(Table3)duringlatentphase,activephaseandtransitionalphase. Whenconsideringthelengthoflabouritwasfoundsignificantdifferencebetweenaromatherapya ndbiofeedbackgroupinfirststageoflabour(p<0.0001).Butnodifference(Table4)werefoundin secondandthirdstageoflabour(p=0.0518,p=1.000respectively).Theassociationoffindingsw ithdemographicandobstetricalscorewasassessedbyusingchi- squaretest.Itwasreportedthatbodymassindex(.2=35.8),natureofonsetoflabourpain(.2=6.9 ),analgesics(.2=43.7),andhistoryofdysmenorrhea(.2=43.7)werehavingassociationwithlab ourpain(Table5).Butnatureofconception(.2=0.011)andregularantenatalcheckup(.2=3.15)i snothavingassociationwithlabourpain. Table 1 MeanandstandarddeviationofpainscoreTime of Assessment Aromatherapy Group Control group Biofeedback Group Mean SD Mean SD Mean SD Latentphase6.20.138.60.57.80.15Activephase7.50.219.00.348.2 0.19Transitionalphase8.30.479.60.219.20.01 Table 2 Mean and standard deviation of Duration of labour Stages of labour in Aromatherapy Group Control group Biofeedback Group hours:mts Mean SD Mean SD Mean SD First stage 11:55 2.4 14:58 2.9 13:52 2.6 Second stage 1:5 0.33 1:58 0.37 1:55 0.15 Third stage 0:28 0.02 0:30 0.05 0:28 0.03 Table 3 Comparison of Pain score between aromatherapy and biofeedback group Pain assessment Groups Mean SD value of �t� P value Result Latent phase Aromatherapy group 6.2 0.13 113.95 P<0.0001 SBiofeed back group 7.8 0.15 Active phase Aromatherapy group 7.5 0.21 34.96 P<0.0001 SBiofeed back group 8.2 0.19 Transitional phase Aromatherapy group 8.3 0.47 27.07 P<0.0001 SBiofeed back group 9.2 0.01 Table 4 Comparison of Duration of labour between aromatherapy and biofeedback group Stages of labour Groups Mean SD value of �t P value Result First stage Aromatherapy group 11.55 2.4 7.87 P<0.0001 SBiofeed back group 13.52 2.6 Second stage Aromatherapy group 1.5 0.33 1.95 P=0.0518 NSBiofeed back group 1.55 0.15 Third stage Aromatherapy group 0.28 0.02 0.000 P=1.000 NSBiofeed back group 0.28 0.03 Table 5 Association of Pain score with selected obstetrical variable Individual reviews showed that there is no significant difference between aromatherapy group and Biofeedback Group. Although morewomeninaromatherapygroupweresatisfiedwithpainrelief (p=0.6443) and caesarean section (p=0.0304) was reduced (Table 6). No women in either group had a postpartum haemorrhage (p=1.000). The findings of the study were concluded that aroma therapy and biofeedback were found effective when compared with control group. S. No. Selected obstetrical variables Pain score Value of .2 P value At 5% Level of significance Result Below Median Above Median 1. Quetelet�s Body mass index a) < 24 b) = 24 132 183 189 96 35.8401 0. S 2. Nature of onset of labour pain a) Spontaneous b) Induced 181 134 133 152 6.9879 0.008206 S 3. Nature of conception a) Assisted b) Natural 05 285 05 305 0.0113 0.915298 NS 4. Analgesics given a) Yes b) No 225 75 30 270 259.335. 0. S 5 History of Dysmenorrhea a) Yes b) No 53 142 175 130 43.7265 0 S 6 Regular antenatal check up a)Yes b)No 138 152 170 140 3.1547 0.07571 NS Discussion This study has evaluated the effectiveness of aromatherapy and biofeedback in reduction of pain and duration of labour during childbirth. Overall there was a slight difference between aroma therapy and biofeedback therapy. But when compared with aroma therapy there was a limited pain reduction in biofeedback therapy. However biofeedback therapy also found effective when compared with control group. Duchene, 1998 reported that 4This article is available in: www.hsj.gr/archive ARCHIVOS DE MEDICINA ISSN 1698-9465 2015 Vol. 9 No. 1:9 Health Science Journal ISSN 1791- 809Xwomenwhopracticedbiofeedback,hadsignificantreductioninlaborpainaccordingtotheMc GillPainQuestionnairescaleandalsoreductionindurationoflabour[10]. Aromatherapyisacosteffectivenonpharmacologicalpainreliefmethod.Thepresentstudyshowe dthat,aromatherapywaseffectiveinreductionofpainanddurationoflabour.Nomaternalandneo nataladverseeffectswereassociatedwitharomatherapy. Themajorityofwomenreportedsatisfactionabouttheirlabourexperience.Toconfirmthis,Chan getal., [11]demonstratedastudyinwhicharomatherapymassagewaseffectiveonpainreductionandallev iationoffearduringlabor.Ourfindingalsoshowedthatmeanpainintensityinfirststageoflabo rwasreducedwhencomparingwithnon- experimentalgroup.ItwasalsosupportedbyanotherstudyconductedbyBurnsetal.,[12] where,theyconcludedthataromatherapywasusefultorelievepainandalsostrengthentheuterin econtractionsduringlabor. TherecentstudybyAbbaspoor, [13]alsoconfirmedthat,lavenderoilmassagewasacosteffectiveinterventionduringchildbir thtodecreasepainanddurationoflabourduringthefirstandsecondstageoflbour.SimilarlyJen nings[14]reportedthatlavenderoilpromotesrelaxation,anditmaygivesootheeffecttotheski nandstimulatethenerveendingswhenapplyinglikeamassage. Lavendermassageusedinaromatherapycanreducethepainduringfirststageoflaboranditcanred uceawiderangeofworstlabouroutcomes.Aromatherapyisanalternativetreatmentduringlabour inreductionofpain,insteadofusingpharmacologicalmethodsofpainrelievers[15].However,t hefinalresultofourstudyalsoshowedthataromatherapywasmoreusefulthanbiofeedbacktherap yanditwascomparedwithcontrolgroup.Aresearchstudyreportedthatlinaloolwhichispresenti nlavenderoilishavingsedativeandlocalanestheticeffect.Thisconstituentmayreducetheper ceptionoflabourpain.Italsoincreasethesecretionofepinephrinewhichmayresponsibleforth ereductionofpainperceptionbythemother[16]. Biofeedbackisalsoavaluabletoolinreductionoflabourpainwhichfacilitatespsychologicali nterventionsthataiddevelopinggreaterskillsfocopingandimprovedfunctioningonmeasureso fpainintensity,adaptivebeliefsaboutpainandthelevelofdepression[17].Duringbiofeedbac ktherapy,electrodeswereattachedtothepatient'sskin,whichsendsdatatoascrutinizingcart on.Thebiofeedbacktherapistreadsthedimensionsandthroughtrialanderrorsignalsoutmental undertakingsthathelpstonormalizethepatient'swhoebodyprocesses[18]. Giardinoetal., [19]statedthat,biofeedbackistomakeapersonwhoisinananxiousstatetobecomeawareofthephy siologicalchangesandsledsmanipulatetobeinarelaxedstate.Sutartoetal., [20]examinedtheeffectofresonantbreathingbiofeedbackteachingfordecreasingstressamong constructingoperators. Outcomesdemonstratedthatdespondency,anxiety,andstresssignificantlydeclinedafterthet raininginexperimentalgroup.Moreoverwhenusedasanadjuncttoothertherapeuticinterventio nsitshownasaneffectivetreatmentforreducingoreliminatingsymptomsofseverapain- relatedconditions, includinglowbackpain[21].Asanon- pharmacologicalnursingintervention,biofeedbacktherapyiseasytoadminister,costeffecti ve,harmless,doesnotrequiremuchtraining,anditisappealingtothemother[22].Thepresentst udyresultsshowedthatbiofeedbacktherapyalsoagoodandeffectivenonpharmacologicalmethod forreductionofpainanddurationoflborwhencomparedwithcontrolgroupwhereas,whencompared witharomatherapy,ithaslesssignificanteffectsonthe both variables. Conclusion Theresultsofthispresentstudysuggesttheuseofaromatherapyandbiofeedbackasaneffectivem ethodofreducingpainperceptionanddurationoflaouramongwomenduringlabor. Asanon- pharmacologicalnursingintervention,theseareeasytoadminister,costeffective,harmless, donotrequiremoretraining, andappealingtothemother.Thisinterventionmaybeusedbyhealthcarepractitioners(midwives ,medicalandnursingstaff, studentnurses)aspartoftheirroutinewhenprovidingcarewithwomenduringthelaborprocess. Acknowledgements Wesincerelythankallwomenwhogaveconsentandparticipatedinthisstudy. Declarations Funding: NofundingsourcesCompeting interests: Therearenocompetingintereststodeclare. Ethical approval: ThestudywasapprovedbytheInstitutionalethicscommittee. Table 6 Resultsbyindividualreview-AromatherapytherapyversusBiofeedbackgroupOutcome No of women in Aromatherapy Group (n=200) No of women in Biofeedback Group (n=200)) RR95%CI p value Positive outcome Negative outcome Positive outcome Negative outcome Painintensity15248148521.02700.9171to1.15010.6443Satisfactionwithpainrelief14852150 500.97370.8695to1.09040.6443Satisfactionwithhildbirthexperience13763135651.01480.88 71to1.16090.8303Assistedvaginalbirth12575130700.96150.8294to1.11480.6032Caesareanse ction7822 180201.09091.0083to1.18030.0304Adverseeffectforwomen(PPH)20000200001.0000.9903to1.0 0981.000Postnataldepression1901018911 1.04420.9873to1.10430.1300Adverseeffectofinfants17822 180201.00530.9600to1.05280.8226APGARScore<7atfirst5minute17921 17228 1.04070.9671to1.11990.2865 This article is available in: www.hsj.gr/archive ARCHIVOS DE MEDICINA ISSN 1698-9465 2015 Vol. 9 No. 1:9 Health Science Journal ISSN 1791- 809Xwomenwhopracticedbiofeedback,hadsignificantreductioninlaborpainaccordingtotheMc GillPainQuestionnairescaleandalsoreductionindurationoflabour[10]. Aromatherapyisacosteffectivenonpharmacologicalpainreliefmethod.Thepresentstudyshowe dthat,aromatherapywaseffectiveinreductionofpainanddurationoflabour.Nomaternalandneo nataladverseeffectswereassociatedwitharomatherapy. Themajorityofwomenreportedsatisfactionabouttheirlabourexperience.Toconfirmthis,Chan getal., [11]demonstratedastudyinwhicharomatherapymassagewaseffectiveonpainreductionandallev iationoffearduringlabor.Ourfindingalsoshowedthatmeanpainintensityinfirststageoflabo rwasreducedwhencomparingwithnon- experimentalgroup.ItwasalsosupportedbyanotherstudyconductedbyBurnsetal.,[12] where,theyconcludedthataromatherapywasusefultorelievepainandalsostrengthentheuterin econtractionsduringlabor. TherecentstudybyAbbaspoor, [13]alsoconfirmedthat,lavenderoilmassagewasacosteffectiveinterventionduringchildbir thtodecreasepainanddurationoflabourduringthefirstandsecondstageoflbour.SimilarlyJen nings[14]reportedthatlavenderoilpromotesrelaxation,anditmaygivesootheeffecttotheski nandstimulatethenerveendingswhenapplyinglikeamassage. Lavendermassageusedinaromatherapycanreducethepainduringfirststageoflaboranditcanred uceawiderangeofworstlabouroutcomes.Aromatherapyisanalternativetreatmentduringlabour inreductionofpain,insteadofusingpharmacologicalmethodsofpainrelievers[15].However,t hefinalresultofourstudyalsoshowedthataromatherapywasmoreusefulthanbiofeedbacktherap yanditwascomparedwithcontrolgroup.Aresearchstudyreportedthatlinaloolwhichispresenti nlavenderoilishavingsedativeandlocalanestheticeffect.Thisconstituentmayreducetheper ceptionoflabourpain.Italsoincreasethesecretionofepinephrinewhichmayresponsibleforth ereductionofpainperceptionbythemother[16]. Biofeedbackisalsoavaluabletoolinreductionoflabourpainwhichfacilitatespsychologicali nterventionsthataiddevelopinggreaterskillsfocopingandimprovedfunctioningonmeasureso fpainintensity,adaptivebeliefsaboutpainandthelevelofdepression[17].Duringbiofeedbac ktherapy,electrodeswereattachedtothepatient'sskin,whichsendsdatatoascrutinizingcart on.Thebiofeedbacktherapistreadsthedimensionsandthroughtrialanderrorsignalsoutmental undertakingsthathelpstonormalizethepatient'swhoebodyprocesses[18]. Giardinoetal., [19]statedthat,biofeedbackistomakeapersonwhoisinananxiousstatetobecomeawareofthephy siologicalchangesandsledsmanipulatetobeinarelaxedstate.Sutartoetal., [20]examinedtheeffectofresonantbreathingbiofeedbackteachingfordecreasingstressamong constructingoperators. Outcomesdemonstratedthatdespondency,anxiety,andstresssignificantlydeclinedafterthet raininginexperimentalgroup.Moreoverwhenusedasanadjuncttoothertherapeuticinterventio nsitshownasaneffectivetreatmentforreducingoreliminatingsymptomsofseverapain- relatedconditions, includinglowbackpain[21].Asanon- pharmacologicalnursingintervention,biofeedbacktherapyiseasytoadminister,costeffecti ve,harmless,doesnotrequiremuchtraining,anditisappealingtothemother[22].Thepresentst udyresultsshowedthatbiofeedbacktherapyalsoagoodandeffectivenonpharmacologicalmethod forreductionofpainanddurationoflborwhencomparedwithcontrolgroupwhereas,whencompared witharomatherapy,ithaslesssignificanteffectsonthe both variables. Conclusion Theresultsofthispresentstudysuggesttheuseofaromatherapyandbiofeedbackasaneffectivem ethodofreducingpainperceptionanddurationoflaouramongwomenduringlabor. Asanon- pharmacologicalnursingintervention,theseareeasytoadminister,costeffective,harmless, donotrequiremoretraining, andappealingtothemother.Thisinterventionmaybeusedbyhealthcarepractitioners(midwives ,medicalandnursingstaff, studentnurses)aspartoftheirroutinewhenprovidingcarewithwomenduringthelaborprocess. Acknowledgements Wesincerelythankallwomenwhogaveconsentandparticipatedinthisstudy. Declarations Funding: NofundingsourcesCompeting interests: Therearenocompetingintereststodeclare. Ethical approval: ThestudywasapprovedbytheInstitutionalethicscommittee. Table 6 Resultsbyindividualreview-AromatherapytherapyversusBiofeedbackgroupOutcome No of women in Aromatherapy Group (n=200) No of women in Biofeedback Group (n=200)) RR95%CI p value Positive outcome Negative outcome Positive outcome Negative outcome Painintensity15248148521.02700.9171to1.15010.6443Satisfactionwithpainrelief14852150 500.97370.8695to1.09040.6443Satisfactionwithhildbirthexperience13763135651.01480.88 71to1.16090.8303Assistedvaginalbirth12575130700.96150.8294to1.11480.6032Caesareanse ction7822 180201.09091.0083to1.18030.0304Adverseeffectforwomen(PPH)20000200001.0000.9903to1.0 0981.000Postnataldepression1901018911 1.04420.9873to1.10430.1300Adverseeffectofinfants17822 180201.00530.9600to1.05280.8226APGARScore<7atfirst5minute17921 17228 1.04070.9671to1.11990.2865 References 1 Sharron SH (2006) The Life-Changing Significance of Normal Birth. J Perinat Educ 15: 1�3. 2 The World Bank (2014) Maternal mortality ratio (modeled estimate, per 100,000 live births). 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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Original Article Original Article Effect of Lavender Oil Aroma in the Early Hours of Postpartum Period on Maternal Pains, Fatigue, and Mood: A Randomized Clinical Trial Abstract Background: Busy care providers focus on the serious complications of postpartum period. This issue causes the seemingly trivial complications, such as mother�s pains, fatigue, and psychological status, to be less taken into account. The study aimed to determine the effect of lavender oil aroma in the early hours of postpartum period on maternal pains, fatigue, and mood in primiparous mothers. Methods: This randomized clinical trial was conducted on 56 participants; 29 in intervention group and 27 in control group. The intervention group received lavender oil in three doses during the first 24 h after delivery. Sesame oil was used in the control group. Intensity of pain, fatigue, and distress level was measured by visual analog scale before and after the interventions. Besides, mood status was assessed through the positive and negative affect schedule. Results: The mean age of all the participants was 23.88 � 3.88 years. After the first intervention and also in the tomorrow morning assessment, significant differences were found between the two groups regarding perineal pain (P = 0.004, P < 0.001), physical pain (P < 0.001), fatigue (P = 0.02, P < 0.001), and distress scores (P < 0.001). In addition, significant differences were found concerning the mean scores of positive (P < 0.001) and negative (P = 0.007, P < 0.001) moods between the two groups after the interventions. Repeated measures analyses showed that the two groups were significantly different over time in all the evaluated variables. Conclusions: Lavender oil aromatherapy starting in the first hours of postpartum period resulted in better physical and mood status compared to nonaromatic group. Keywords: Fatigue, lavender oil aromatherapy, mood, perineal pain, postpartum Introduction The mothers who give birth in maternity wards are under the supervision of skilled personnel in the immediate postnatal period and are monitored regarding the life-threatening conditions, such as bleeding, hypertension, and infection.[1,2] In addition to fatal complications, mothers in the immediate postpartum period may suffer from some problems, such as perineal pain, back pain, uterine cramps, and fatigue. Busy care providers focus on the serious complications of postpartum period. This issue causes the seemingly trivial complications, such as mother�s perineal pain, fatigue, and psychological status, to be less taken into account.[1,3,4] In addition, mothers may consider these problems as the natural consequences of labor and speak less about them.[5] Perineal pain as well as other physical pain in the postpartum period can lead to insomnia, fatigue, confusion, anxiety, delay in the This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact:
[email protected] formation of relationship between the mother and her baby, disability in caring about the newborn, and inappropriate body position during breastfeeding. In severe pain and immobility cases, there is also a risk of deep vein thrombosis.[5,6] Perineal pain can be treated by a variety of oral analgesics, rectal suppositories, and topical anesthetics. In a previous study, only about 63% of the mothers described that painkillers were effective in relief of perineal pain.[3] In our society, sedative drugs such as mefenamic acid are routine care managements of pain such as perineal pain after delivery. Sedative drugs act in relative manners that need other complementary methods. Besides, these drugs have some serious effects that result in limiting consumption. It should be noted that, in most cases in Iran, mediolateral incision is made for episiotomy and catgut thread is used for its repair, resulting in more perineal pain.[1,7] How to cite this article: Vaziri F, Shiravani M, Najib FS, Pourahmad S, Salehi A, Yazdanpanahi Z. Effect of lavender oil aroma in the early hours of postpartum period on maternal pains, fatigue, and mood: A randomized clinical trial. Int J Prev Med 2017;8:29. Farideh Vaziri, Mahsa Shiravani1, Fatemeh Sadat Najib2, Saeedeh Pourahmad3, Alireza Salehi4, Zahra Yazdanpanahi Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran, 1Student Research Committee, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran, 2Department of Obstetrics and Gynecology, Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran, 3Department of Biostatistics, Medical School, Shiraz University of Medical Sciences, Shiraz, Iran, 4Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Address for correspondence: Farideh Vaziri, Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Zand Street, Shiraz, Iran. E-mail:
[email protected] Access this article online Website: www.ijpvmjournal.net/www.ijpm.ir DOI: 10.4103/ijpvm.IJPVM_137_16 Quick Response Code: Therefore, a lot of women in Iran and other countries (with similar above-mentioned midwifery background) need to be relieved from perineal pain during the first 24 h postpartum. Conventionally, fatigue and lack of energy have been accepted as the common consequences of childbirth in the postpartum period. In the past two decades, fatigue has been one of the five most important issues for women in the postpartum period. Fatigue is a condition that causes the mother to have negative feelings and be uncomfortable.[8,9] Lavender is an aromatic plant that is widely used in aromatherapy. Researches have indicated that aromatherapy with lavender has anti-inflammatory, anti-depressant, hypnotic, sedative, muscle-relaxant, anti-bacterial, and anti-spasmodic effects.[10,11] Aromatherapy with lavender oil has been used to reduce pain and anxiety during labor, and mothers have generally evaluated this approach as an appropriate method.[12] Considering the implementation of rooming-in method in most maternity wards, it is important that mothers experience less pain and fatigue, have a good mood to establish an appropriate emotional relationship with their infants in the early hours of postpartum period, and can breastfeed and take care of their infants. Obviously, supportive efforts from care providers result in an successful initiation of breastfeeding that causes it to be continued after release from hospital.[13] Discharge with better physical and mental conditions in turn improves women�s quality of life.[14,15] Thus, the present study aims to assess the effect of lavender oil aroma in the early hours of postpartum period on maternal physical pains, fatigue, and mood in primiparous women. Methods Participants and setting This clinical trial was conducted on 56 primiparous women with normal vaginal delivery in one educational hospital affiliated to Shiraz University of Medical Sciences. The participants were under the immediate postpartum care in the postpartum wards. Data collection was performed from the second half of April to late June 2014. This study was confirmed by the Ethics Committee of Shiraz University of Medical Sciences (code: CT91-6943). The investigation was also registered in the Iranian Registry of Clinical Trials as IRCT2014060910327N7. The inclusion criteria of the study were vaginal delivery with episiotomy and without spinal or epidural anesthesia, singleton pregnancy, live and normal infant, aged 18�35 years, not suffering from severe chronic diseases such as cardiovascular and lung disease, at least 4 h later than delivery, perineal pain score =4 in visual analog scale (VAS), and having no history of allergy to lavender plant. On the other hand, in case the mothers were not willing to continue participation in the study, could not bear the smell of lavender essential oil, and were susceptible to complications such as hypertension, bleeding, and fever, they were excluded from the study. In the postpartum ward, the researcher selected the participants based on the patients� records and interviews. After description of the study objectives, the mothers were encouraged to participate in the study, and if they were willing, written informed consents were obtained from them. Due to the possible emergency problems in the first hour of postpartum, sampling was done after this period. Tools and data collection In the present study, physical pain was defined as back pain, muscle pain, and uterine cramps. In addition, perineal pain was considered as a pain in the external genitalia. Before the intervention, the primiparous mothers were asked to indicate the intensity of the above-mentioned pain by VAS. If the mothers showed pain intensity =4, they were enrolled into the study. A pain VAS scale is a 100 mm horizontal line, representing no pain at the commence and the worst possible pain at the end.[16] A fatigue VAS scale, a 100-mm horizontal line quantifying fatigue between the anchors �no fatigue� and �fatigue as bad as can be, measured the fatigue.� With insertion of a spot on the line, the participant expressed how much fatigue she was experiencing at the study point time. Distress perception was also assessed by VAS, fixed with feeling rested at the beginning and completely distressed at the end.[17] In our study, before the first intervention, test-retest analyses showed the correlations of 0.93 and 0.90 for fatigue and peace perception, respectively. Moreover, the mothers� mood was evaluated by the Positive and Negative Affect Schedule (PANAS). This scale consisted of 10 items for assessing the negative moods and 10 items for evaluating the positive ones, which were mixed in the PANAS. The items of this questionnaire were responded through a Likert scale ranging from 1 to 5. Thus, the total scores of both positive and negative moods varied from 10 to 50.[18] It should be noted that the total scores of positive and negative statements were analyzed separately. In this study, for positive section of the PANAS, we obtained a Cronbach�s alpha and a test-retest correlation value of 0.88 and 0.85, respectively. In addition, for negative section of the PANAS, a Cronbach�s alpha and a test-retest correlation value of 0.87 and 0.89 were obtained, respectively. Interventions In this study, the participants were selected by convenience sampling. Then, they were randomly divided into a control and an intervention group through block randomization. In the intervention group, lavender oil was utilized. Lavandula officinalis species was bought from the International Journal of Preventive Medicine 2017, 8: 29 pharmacy of traditional medicine affiliated to Shiraz University of Medical Sciences and its essence was obtained using Apparatus Clevenger in the pharmacology laboratory of School of Medicine, Shiraz University of Medical Sciences. One percent lavender essential oil was provided by the laboratory technician. The researcher instilled five drops of lavender essential oil on a cotton ball and asked the participants to hold it about 20 cm from their nose for 10�15 min and breathe normally. One hour later, the participants� physical pain, fatigue, and mood were evaluated. The intervention with lavender oil was repeated 6 h after the first intervention and at bed time. In the following morning before discharge, the participants� physical pain, fatigue, distress, and mood were measured again. At present, there are no instructions in the Western countries in setting standards for essential oils, and oils are not regulated by the Food and Drug Administration. There is not a great amount of published rigorous research testing aromatherapy oils and techniques; therefore, consensus is lacking on these subjects. Researchers selected the dose and intervals of consumption anecdotally. Exactly 1 to 2% concentration of lavender oil was used intrapartum to manage labor pain and anxiety without any harm for mother or her fetus. Therefore, we followed this method in our study.[19] The previous study showed that lavender aroma in infancy was not harmful.[20,21] However, in the present study, we used low concentration of lavender oil (1%), and for more caution, the mother was separated from her baby during the aromatherapy period. In the control group, sesame oil was used as placebo similar to lavender oil in intervention group as mentioned above. Sesame oil was provided from Oila Company (manufactured in Tehran, Iran). The participants were blinded for the types of the oils; therefore, the study was a single-blinded study. The two study groups received routine postpartum care including sedative drugs. Sample size and statistical analysis Based on a previous study,[22] considering a = 0.05 and power of 80%, and using the statistical formula, a 60-subject sample size was determined for the study. The data were analyzed using SPSS statistical software version 16 (SPSS Inc., Chicago, IL, U.S.A). Besides, P < 0.05 was considered statistically significant. At first, normality of distribution of quantitative variables was assessed by one-sample Kolmogorov�Smirnov test. If the variables followed normal distribution, independent samples t-test was used; otherwise, its equivalent nonparametric test, i.e., Mann�Whitney U-test, was employed. In addition, repeated measures analysis of covariance was applied to determine changes over time in each group. Chi-square test was also used for investigation of the qualitative variables. Results In this study, 76 primiparous women were interviewed, 62 of whom were eligible for the study and six women were excluded from the study due to discharge from the hospital before the end of the study. After all, the data of 56 participants (29 in the intervention group and 27 in the control group) were analyzed. The participants� age ranged from 18 to 32 years, with a mean age of 23.88 � 3.88 years. In addition, 51.8% (n = 29) of the participants had primary and high school education, 33.9% (n = 19) had high school diplomas, and 14.3% (n = 8) had university education. All the participants were homemakers. It should be noted that the two groups were matched regarding age (P = 0.39) and education level (P = 0.54). The baseline severity of perineal pain was 70.55 � 17.92 in all the participants with a minimum and maximum of 40 and 100, respectively. Before the intervention, the mean perineal pain was not statistically different between the two groups (P = 0.82). However, a significant difference was observed between the two groups after the first intervention and at the tomorrow morning assessment. The intragroup comparisons showed that the intensity of perineal pain differed only in the intervention group over time (P < 0.001) [Table 1]. According to Figure 1, two groups were different with regard to perineal pain along time. The baseline severity of other physical pain, such as back pain and uterine cramps, was 62.64 � 20.12 and 69.54 � 23.29 in the intervention and control groups, respectively, and the difference was not statistically significant. Nevertheless, a statistically significant difference was found between the two groups after the interventions (P < 0.001) [Table 1]. The baseline severity of fatigue in the whole sample was 40.19 � 15.59, with a minimum and maximum Figure 1: Within-groups comparison related to the perineal pain scores: The results showed, between the two groups, the difference regarding over-time reduction of the perineal pain scores was statistically significant (P < 0.001) International Journal of Preventive Medicine 2017, 8: 29 Table 1: Comparison of the perineal and physical pain, fatigue, distress, and Positive and Negative Affect Schedule measurements between the two groups Variables Time point Mean�SD* P Before the After the first The tomorrow Time.,.. Group.,� Time � group.,� intervention intervention morning assessment Perineal pain Lavender 70.03�19.12 60.93�23.51 46.37�20.67 <0.001 0.001 <0.001 Control 71.11�16.88 77.00�16.00 74.48�15.01 P** 0.825 0.004 <0.001 Physical pain Lavender 62.64�20.12 34.51�36.23 18.75�20.51 <0.001 <0.001 <0.001 Control 69.54�23.29 70.54�24.39 59.36�31.82 P*** 0.240 <0.001 <0.001 Fatigue Lavender 41�16.25 30.95�15.86 21.68�14.30 <0.001 0.02 <0.001 Control 39.33�15.11 40.33�14.46 38.22�15.14 P** 0.69 0.02 <0.001 Distress perception Lavender 26.20�18.65 17.13�17.28 8.55�11.53 0.04 0.009 <0.001 Control 24.74�15.88 25.40�17.42 32.85�19.66 P** 0.85 0.05 <0.001 Positive affect schedule Lavender 36.27�3.31 39.41�3.01 42.75�3.22 <0.001 <0.001 <0.001 Control 36.29�2.86 36.18�2.82 36.62�2.84 P*** 0.908 <0.001 <0.001 Negative affect schedule Lavender 13.68�4.06 11.20�1.54 10.37�0.62 0.003 <0.001 0.05 Control 12.74�2.86 12.88�2.77 13.55�3.81 P** 0.532 0.007 <0.001 *Mean�SD, **Student�s t-test, ***Mann-Whitney test, .Repeated measures test, ..Within-subjects results, �Between-groups results, �Interaction between groups and time. SD=Standard deviation of 8 and 88, respectively. Before the intervention, no significant difference was observed between the intervention and control groups regarding the intensity of fatigue (P = 0.69). However, significant differences were observed between the two groups after the first intervention and at the tomorrow morning assessment (P = 0.02 and P < 0.001, respectively). The intragroup comparisons also showed that the intensity of fatigue followed a descending trend in the lavender oil group, but not in control group (P < 0.001 and P = 0.44, respectively) [Table 1 and Figure 2]. Between-group analyses showed that mean scores of distress in the lavender oil group were significantly lower compared to the control group at the tomorrow morning assessment (P < 0.001). Besides, the two groups were significantly different along time [Table 1]. The highest scores of positive and negative moods were 42/50 and 24/50, respectively. The mean score of negative moods was 13.23 � 3.53 at baseline and 11.91 � 3.10 in the tomorrow morning assessment. These measures were, respectively, obtained as 36.28 � 3.07 and 39.80 � 4.32 for positive moods. The results showed no significant difference between the intervention and control groups concerning the baseline negative and positive mood scores. Figure 2: Within-groups comparison related to the fatigue scores: The results showed, between the two groups, the difference regarding over-time reduction of the fatigue scores was statistically significant (P< 0.001) After the first intervention and at the tomorrow morning assessment, however, significant differences were found between the two groups regarding the negative and the positive mood scores [Table 1]. Moreover, the intragroup comparisons showed that the intervention group�s positive International Journal of Preventive Medicine 2017, 8: 29 and negative mood scores significantly differed in the three assessment times (P < 0.001) [Table 1]. The results of repeated measures analysis (time effect, group effect, and interaction between time and groups) were shown in Table 1 for all variables. Discussion The result showed that aromatherapy with lavender oil was effective in reducing pain, fatigue, and distress and could improve maternal mood. One of the strong points of this study was including a control group. Although mother�s physical pain and fatigue may decrease by resting after delivery, the effectiveness of the intervention was determined after comparison with the control group. In addition, over-time analyses (repeated measures analyses) revealed that pain, fatigue, and distress decreased as well as mothers� mood improved in the intervention group. Nevertheless, the following points should be noted in the control group. In this group, the severity of perineal pain increased after the first intervention and in the tomorrow morning assessment compared to before the intervention; however, the differences were not statistically significant. Furthermore, the mean intensity of fatigue importantly increased in the tomorrow morning assessment compared to before the intervention. The negative mood scores in the PANAS questionnaire could vary from 10 to 50. Overall, our participants had a low mean score of negative moods, in such a way that the mean scores of negative moods were 13.23 � 3.53 and 11.91 � 3.10 before the intervention and in the tomorrow morning assessment, respectively. These low mean scores might have resulted from the euphoria of motherhood. In contrast to the intervention group, the mean scores of negative moods followed a rising trend in the control group over time. However, the differences were not statistically significant. The positive mood scores showed no significant changes in the control group over time. These findings also demonstrated the effectiveness of lavender essential oil. We could find no similar studies investigating the effect of inhalation aromatherapy on pain relief, reduction of fatigue, and improvement of mood during the first 24 h after vaginal childbirth. However, several studies have been conducted on postcesarean delivery pain and showed that lavender aromatherapy could relieve postcesarean delivery pain.[23-25] Furthermore, the effects of lavender oil sitz bath on perineal pain have been assessed in some studies. The results of the study by Sheikhan et al. showed that lavender oil sitz bath group experienced less perineal pain at 4 h and 5 days after delivery.[22] Nevertheless, Vakilian et al. reported that the intensity of perineal pain in the lavender oil sitz bath group was not less than that of the control group.[26] Different study population and accuracy in sample selection could lead to obtain dissimilar results in these studies. Postpartum fatigue starts soon after delivery, gets more intense as time progresses, and may not be recovered spontaneously.[27] Fatigue can interfere in the activities of the new mothers and may also expose them to postpartum blues and depression. Fatigue can occur due to various factors, such as length of labor, type of delivery, postpartum hemorrhage, perineal pain, and other physical pain.[8] By shortening the duration of postpartum hospitalization, health-care providers have lower opportunity to evaluate and manage the above-mentioned complication; therefore, the first 24 h after delivery is a critical time point. In the study conducted by Lee, aromatherapy with lavender oil inhalation was used 6 days after delivery to reduce fatigue and improve sleep. Aromatherapy was given by a necklace from 2 to 8 pm. At the end, the intervention group reported less fatigue compared to the control group.[28] Evidence has shown the importance of mother�s mood in the 1st day postpartum and gives us an idea about the need for appropriate actions. A link between the maternal mood scores in the early days of postpartum and the mood scores at 4, 6, 8, and 12 weeks after birth has been reported.[29-31] The prior studies using aromatherapy in the postpartum period and maternal mood were different from the present one with respect to aromatherapy methods and assessment instruments. These studies have shown the positive effect of aromatherapy on mood in the postpartum period.[32,33] In the study by Imura et al., after 30 min aromatherapy massage, maternal blues and anxiety were measured. The anxiety scores of the aromatherapy massage group was significantly lower compared to the routine care group, and none of them had maternal blues.[32] Studies in other fields of medicine have also confirmed that lavender oil might reduce anxiety and enhance mood scores.[34-36] The present study has some limitations as follows: the participants were selected from one maternity center. This group of participants may not be representative of the target population; sample size was small and we did not control some confounder variables such as duration of labor and psychological status during pregnancy; and our study was done in a short period (24 h after delivery) and the effect of such intervention was not assessed through the following days or weeks. Hence, longer studies are recommended to elucidate the effect of aromatherapy on maternal morbidities during the early and late postpartum periods. Conclusions In addition to the serious complications of labor and delivery that may be fatal for mothers during the first 24 h postpartum, other complications, such as physical pain and fatigue, may also upset the mothers and decrease the quality of their performance. To the best of our knowledge, this study was the first to examine the effectiveness of inhalation aromatherapy on the mothers� perineal and International Journal of Preventive Medicine 2017, 8: 29 physical pain, fatigue, distress, and mood during the immediate postpartum period. The findings showed that inhalation aromatherapy practice in the early hours of postpartum could reduce the mothers� pain and fatigue and improve their mood. Acknowledgments This paper was extracted from Ms. Mahsa Shiravani's M.S. thesis in midwifery approved by Shiraz University of Medical Sciences (proposal no. 92-6943). Thanks also goes to all the participants who took part in this research. Financial support and sponsorship The study was financially supported by the Research Vice-chancellor of Shiraz University of Medical Sciences. Conflicts of interest There are no conflicts of interest. Received: 20 Apr 16 Accepted: 14 Feb 17 Published: 04 May 17 References 1. Cunningham FG, Levono KJ, Bloom SL, Hauth JC, Rouse DJ, Spoong CY. Williams obstetrics. 23th ed., Ch. 17, Sec. 4. New York: The McGraw-Hill Companies; 2010. 2. Walsh D. A review of evidence around postnatal care and breastfeeding. Obstet Gynaecol Reprod Med 2011;21:346-50. 3. East CE, Sherburn M, Nagle C, Said J, Forster D. Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery 2012;28:93-7. 4. Yelland J, McLachlan H, Forster D, Rayner J, Lumley J. How is maternal psychosocial health assessed and promoted in the early postnatal period? Findings from a review of hospital postnatal care in Victoria, Australia. Midwifery 2007;23:287-97. 5. Amorim Francisco A, Junqueira Vasconcellos de Oliveira SM, Barbosa da Silva FM, Bick D, Gonzalez Riesco ML. Women�s experiences of perineal pain during the immediate postnatal period: A cross-sectional study in Brazil. Midwifery 2011;27:e254-9. 6. Way S. 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J Assoc Chart Physiotherapists Womens Health 2008;103:12-6. 13. Brand E, Kothari C, Stark MA. Factors related to breastfeeding discontinuation between hospital discharge and 2 weeks postpartum. J Perinat Educ 2011;20:36-44. 14. Atlantis E, Chow CM, Kirby A, Singh MF. An effective exercise-based intervention for improving mental health and quality of life measures: A randomized controlled trial. Prev Med 2004;39:424-34. 15. Connell J, Brazier J, O�Cathain A, Lloyd-Jones M, Paisley S. Quality of life of people with mental health problems: A synthesis of qualitative research. Health Qual Life Outcomes 2012;10:138. 16. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 2001;8:1153-7. 17. Wolfe F. Fatigue assessments in rheumatoid arthritis: Comparative performance of visual analog scales and longer fatigue questionnaires in 7760 patients. J Rheumatol 2004;31:1896-902. 18. Crawford JR, Henry JD. 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Modulatory effects of aromatherapy massage intervention on electroencephalogram, psychological assessments, salivary cortisol and plasma brain-derived neurotrophic factor. Complement Ther Med 2014;22:456-62. 36. Cho MY, Min ES, Hur MH, Lee MS. Effects of aromatherapy on the anxiety, vital signs, and sleep quality of percutaneous coronary intervention patients in Intensive Care Units. Evid Based Complement Alternat Med 2013;2013:381381. International Journal of Preventive Medicine 2017, 8: 29 Reproduced with permission of copyright owner. Further reproduction prohibited without permission. Aromatherapy as a Comfort Measure During the Childbearing Year by Virginia Coleman Smith, MSN FNP-BC ICCE Abstract: Aromatherapy, considered a part of complementary and alternative medicine (CAM), is the use of plant-based essential oils for their many health- inducing properties including relaxation, anti-inflammatory, microbial, spasmodic, and pain relief. Used with knowledge and caution, the introduction of essential oils into one�s practice during the childbearing year can offer a natural, therapeutic element that lifts the spirits and supports a healing environment for the body. key words: essential oils, aromatherapy, comfort measure, Pregnancy, childbearing Aromatherapy in the Childbearing Year For thousands of years the use of plant-based essential oils has been effective in meeting a variety of health-related needs (Enteen, 2011). The term aromatherapy was coined by Rene-Maurice Gatteefosse, a French chemist who experimented with essential oils for wound healing during World War I (as cited in Butje, Rapede, & Shattell, 2008). Gatteefosse successfully treated, with lavender, a severe burn incurred in his laboratory. This incident inspired him to pursue research into the therapeutic applications of essential oils (Horowitz, 2011; Enteen). Aromatherapy is considered Complementary and Alternative Medicine (CAM) and possesses anti-inflammatory, anti-microbial, anti-anxiety, anti-spasmodic, and anti-pruritic properties. Aromatherapy provides many benefits from natural sources that address needs arising during the childbearing year (Tillett & Ames, 2010). Enjoying more popularity in the U.K. and Europe, with availability reportedly at 76% in German obstetric departments, aromatherapy is only recently being introduced into U.S. hospitals and clinics (Seol et al., 2010; Horowitz, 2011; Conrad, 2010). Although studies vary regarding the success of aromatherapy in labor management, research indicates that the use of essential oils can reduce anxiety, nausea, and the need for pain medication, as well as provide a holistic approach to caring for women during the childbearing period (Wray, 2011; Conrad, 2010; Smith, Collins, & Crowther, 2011). Essential oils affect the brain�s limbic system by way of the olfactory nerve and have calming, relaxing or invigorating effects (Horowitz, 2011). Research into the specific effects on mood, memory, and cognition has shown lavender and rosemary to be stress reducers, with lavender having a more relaxing, drowsy effect and rosemary stimulating more cognition and memory (McCaffrey, Thomas, & Kinzelman, 2011). Pure essential oils are volatile and concentrated. Oils should be stored in dark glass containers, away from sunlight, and blended in carrier oils to dilute their potency and avoid irritating the skin. Sweet almond (Prunus Amygdalus), contraindicated for those with a nut allergy, grapeseed (Vitis vinifera), and sesame (Sesamum indicum) are the preferred carrier oils and contain Vitamin E or A, making them acceptable �stand alone� products for massage (Tillett & Ames, 2010). Pure oils, rather than mixed with mineral oil, are preferred for maximum absorption (Raab, 2010). A patch test should be conducted initially to determine any allergies; but, as a general rule, aromatherapy is considered safe and effective with a therapeutic outcome (Tillett & Ames, 2010). During the 2004 International Childbirth Education Association (ICEA) conference in Baltimore, aromatherapy continued on next page 26 | International Journal of Childbirth Education | Volume 27 Number 3 July 2012 Aromatherapy as a Comfort Measure continued from previous page was the topic of a �break-out session.� Information regarding essential oil properties, usage, and methods of delivery was provided for participants, as well as an opportunity to sample from a wide variety of essential oils. The session presented aromatherapy beyond a cosmetic framework into one of essential oils having a practical and therapeutic application. Class participants learned about essential oils for specific outcomes and left the session with additional options in providing comfort to pregnant/laboring/and postpartum women. Caution Because essential oils are highly concentrated substances with chemical components, toxicity must be considered � especially when working with women in the childbearing year (Wray, 2011; Conrad, 2010). Several caveats to keep in mind include the following: using the lowest doses possible to achieve the desired effect; avoiding sun exposure after using citrus oil; avoiding the use of an essential oil over a prolonged period of time; and refraining from the use of essential oils during the first trimester, when the majority of fetal development is occurring (Tiran, 1996). Knowledge of the properties of the essential oils that are being used will guide practice. For instance, clary sage and fennel have estrogenic effects that may increase uterine contractility. These properties are useful during labor, but contraindicated in pregnancy. Nutmeg and cinnamon, while effective pain relievers, are also cardiac stimulants and should be avoided during pregnancy when cardiac volume increases by 40% (Beckmann, 2010; Tiran, 1996). Using herbs from the garden can be an acceptable way to enjoy a fragrance yet avoid the high concentration of essential oils. Because essential oils are highly concentrated substances with chemical components, toxicity must be considered � especially when working with women in the childbearing year Essential oils are lipophilic, blending easily into fat soluble carrier oils, which are absorbed into the skin and can cross the placenta (Tillett & Ames, 2010). Essential oils used in massages cross into the bloodstream between 10 and 30 minutes after application, a much shorter than the normal 30 minute time frame for pain medications to take effect (Dunning, 2005), and are quite effective at allaying anxiety, reducing stress, and relaxing tense muscles. When adding aromatherapy to one�s care of women during the childbearing year, it is wise to begin with just a few essential oils whose properties are familiar and to use only one at a time. Because misleading information and impure products are readily available by internet and in shops, choosing reputable sources for information and products is important. Keeping safety and knowledge at the core of one�s practice increases the likelihood of success and longevity in a caregiving profession (Tiran, 2011). Pregnancy Pregnancy, often a time of physical discomforts and emotional instability, is an ideal time to introduce women to the stress-reducing and mood elevating effects of aromatherapy. The rapidly approaching labor and delivery experience and the concept of becoming a parent contribute to the anxiety that is frequently seen in pregnant women (Smith, 2012). Because some women may have a hypersensitive reaction to certain essential oil blends, conducting a patch test in a small area of skin is important before application to a larger area of the body. From the calming, sedating effect of lavender to the uplifting, energizing effect of mandarin, the range of therapeutic benefits of aromatherapy is impressive (Horowitz, 2011; McCaffrey, Thomas, & Kinzelman, 2009). Bergamot, lemon and grapefruit are ingredients found in hard candies made especially to combat nausea. Small doses of peppermint and ginger in the form of a tea, spritz, or candle- infused with essential oils are especially good for tension and upset stomach (Toda & Morimoto, 2011). The aromatherapy sock, made from a tube sock, contains dry white rice infused with essential oils. Warmed in the microwave, it can be used as a neck/back wrap or placed beneath the pregnant abdomen to provide comfort between contractions. The sock can be personalized with essential oils suited to individual preferences and makes a nice gift for use during the childbearing year. continued on next page Debra Rose Wilson Volume 27 Number 3 July 2012 | International Journal of Childbirth Education | 27 Aromatherapy as a Comfort Measure continued from previous page In the last trimester, a daily perineal massage prepares the delicate tissue of the perineum for the stretching that will occur during delivery. By increasing circulation and enhancing tissue elasticity, the perineal massage with a combination of lavender and chamomile blended into almond or grapeseed oil reduces perineal trauma (Beckmann & Garrett, 2009). Childbirth Class The childbirth educator, encouraging efforts that relax, calm, and distract, can maximize the motivation of class participants who are eager for suggestions to prepare for labor and delivery. Comfort measures using aromatherapy can give the mother and her partner more of a sense of control. A foot soak of peppermint, a back massage with mandarin, rose, or ylang ylang, or a hand massage with eucalyptus are examples of comfort measures with essential oils that can be taught in childbirth class (Conrad, 2010). Partners are always open to ideas that will help them be more effective during the labor experience. Massage, with its proven effects of reducing stress hormone levels, as well as relaxing tense muscles, is an easy tool to put in their kit of comfort measures. Playing music with nature sounds from a rainforest or the ocean, offering a basket of blended essential oils, lotions, and massage tools for neck or hand massage, and providing the time at the close of the class, sets the stage for breathing and relaxation. The calming benefits of touch, along with the stress and pain reducing properties of aromatherapy are reinforced as the breathing and relaxation sessions offer the laboring couple the opportunity to put it all together in dress rehearsal fashion. Labor and Delivery If the milder contractions of early labor are a challenge, a warm tub, foot soak, massage, or warm sock wrap with lavender and chamomile provides distraction and relaxation for the woman and �something to do� for the coach, who is eager to help but not sure what is effective. Lavender, mandarin and rose can be especially good in early labor when the woman, frustrated with the pace of labor progression, may be more anxious (Tillett, 2010; Conrad, 2010; Pollard, 2008). Active and transition stages of labor may benefit from the warming quality of frankincense, jasmine, and peppermint, as a back massage, compress to the forehead or abdomen (Pollard, 2008; Horowitz, 2011). Peppermint, shown to �reduce cortisol levels and increase chromogranin A (CgA) levels, a chemical associated with moderate, positive eustress� is a great choice along with its anti-nausea property (Toda & Morimoto, 2011, p. 432). Clary sage, a multi-purpose essential oil during active labor, increases uterine contractility and acts as a stress reducer and anti-depressant, much like the action of dopamine (Seol et al, 2010). The clean, refreshing aroma of eucalyptus is a favorite for labor and delivery. It provides anti-microbial activity that, along with thyme, has a synergistic effect against strains of Methicillin-Resistant Staphylococcus Aureus (MRSA) (Tohidpour et al., 2010). Postpartum Hormones plummeting to menopausal levels, chaotic sleep routines, and a preoccupation with infant behaviors contribute to the disorientation of postpartum. With the increased demands of the newborn and self-care, the postpartum woman may benefit from a diffuser as the most effective delivery method to experience the benefits of essential oils. Postpartum is a time that offers more options of essential oils, as the concerns of pregnancy are left behind. continued on next page Brooke Kelly 28 | International Journal of Childbirth Education | Volume 27 Number 3 July 2012 Aromatherapy as a Comfort Measure continued from previous page Geranium, fennel, and clary sage with their estrogenic and diuretic properties, can be used in the bath, massage, or linen spray (Tillett & Ames, 2010). Uplifting and emotionally balancing neroli, jasmine, and rose are good additions to a tub soak, when someone else is holding the baby and mom has a few moments to herself. Promoting calming and relaxation, ylang ylang has sedative properties, which are beneficial when trying to catch up on much needed sleep (Tiran, 2011). The combination of chamomile and lavender, with anti- inflammatory properties, can be a comforting compress for incisional discomfort of episiotomy or cesarean section. For short episodes of baby blues, a lavender and juniper bath, useful in PMS with fluid retention, as well as neroli, ylang ylang or clary sage as a massage on the chest or abdomen can be soothing (Tillett & Ames, 2010). Breast tenderness benefits from evening primrose oil, juniper, geranium, or the anti-inflammatory property of frankincense (Tillett & Ames, 2010). The antispasmodic properties of essential oils can be especially helpful with multigravidas having uterine cramping. A warm compress, rice sock, or tub soak with fennel, ginger, lavender, or bergamot can assist in relaxing tense muscles (Butje et al., 2008). Infant Care The benefit of using natural baby products is becoming increasingly accepted because many items containing essential oils are now being offered on the market. A cautionary word regarding infants and aromatherapy: most experts agree no essential oils should be used on the infant in the first 6 weeks and even after very few and small amounts. Bronchospasm has been reported. Eucalyptus should be avoided in young children, as it is potent and can overwhelm their fragile nervous system (Osborn, 2004). most experts agree no essential oils to be used on the infant in the first 6 weeks, and even after very few and in small amounts In using aromatherapy with infants and young children, a small amount, 1 drop in 1 ounce of carrier oil is a good safety rule. Lavender, in a randomized control trial, has been shown to be effective in reducing symptoms of colic (�etinkaya & Basbakkal, 2012). One drop of lavender, diluted in an ounce of grape seed oil, is an effective product for infant massage, offering gentle touch in combination with the soothing benefits of this essential oil. Implications for Practice When childbirth educators, doulas, and labor and delivery nurses are open to the vast array of comfort measures, including aromatherapy, that are available, they can be an excellent resource to women looking for an alternative to medicinal treatment of the aches, pains and stresses that accompany the childbearing year (Conrad, 2010; Horowitz, 2011; Butje et al., 2008). Collecting an assortment of products is made easier by taking advantage of seasonal sales at shops that offer pure essential oils. Experimenting with essences that have personal appeal is a good place to start in assembling a supply of essential oils. Local health food stores, apothecaries and reputable websites such as mountainroseherbs.com are potential resources. Some essential oils such as melissa, rose, and jasmine, are extremely expensive. Chamomile, frankincense and sandalwood are fairly inexpensive, as are lavender, rosemary, and orange (Enteen, 2011). Beware of same-pricing for all essential oils, as this indicates a lower grade product. Growing herbs in the garden with the fragrance of lavender, rosemary, thyme, lemon verbena, and rose can be a heady, relaxing experience that translates to immediate access to the essential oils in bath and practice. Just offering a back or hand massage with an uplifting peppermint lotion can open up the topic of stress reduction. Then, the client is breathing deeply, and tense muscles are beginning to relax. References Beckmann, M. & Garrett, A. (2009). Antenatal perineal massage for reducing perineal trauma, Cochrane Reviews retrieved May 8, 2012 at http: summaries. cochrane.org/CD005123/antenatal-perineal-massage-for-reducingperineal- trauma Beckmann, R., Ling, F., Barzansky, B., Herbert, W., Laube, D., Smith, R. (2010). Obstetrics and Gynecology, 6th edition, Lippincott, Williams & Wilkins: St. Louis. Butje, A., Repede, E., Shattell, M. (2008). Healing scents: An overview of clinical aromatherapy for emotional distress. Journal of Psychosocial Nursing & Mental Health Services, 46(10), 46-52. continued on next page Volume 27 Number 3 July 2012 | International Journal of Childbirth Education | 29 Aromatherapy as a Comfort Measure continued from previous page �etinkaya, B., & Basbakkal, Z. (2012). The effectiveness of aromatherapy massage using lavender oil as a treatment for infantile colic. International Journal of Nursing Practice, 18(2), 164-169. doi:10.1111/j.1440172X. 2012.02015.x Conrad, P. (2010). Aromatic childbirth: Developing a clinical aromatherapy maternity program. Beginnings, 30(4), 12-14. Dunning, T. (2005). Applying a quality use of medicines framework to using essential ils in nursing practice, Complementary Therapies in Clinical Practice, 11, 172-181. Enteen, S. (2011). Basic Aromatherapy: Recognize and Offer High Quality, Massage Today, 11(1), 1-6. Horowitz, S. (2011). Aromatherapy: Current and emerging applications. Alternative & Complementary Therapies, 17(1), 26-31. doi:10.1089/ act.2011.17103 McCaffrey, R., Thomas, D., Kinzelman, A. (2009). The effects of lavender and rosemary essential oils on test-taking anxiety among graduate nursing students, Holistic Nursing Practice, 23(2), 88-93. Osborne, K. (2004). Small doses: Aromatherapy for children, Massage and BodyWork, April/May, 140-144. Pollard, K. R. (2008). Introducing aromatherapy as a form of pain management into a delivery suite. Journal of the Association of Chartered Physiotherapists in Women�s Health, (103), 12-16. Raab, A. (2010). Aromatherapy in the intensive care unit: An overview. CONNECT: The World of Critical Care Nursing, 7(2), 127-130. Seol, G. et al. (2010). Antidepressant-like effects of Salvia sclarea is explained by modulation of dopamine activities in rats, Journal of Ethnopharmacology, 130, 187-190. Smith, C. A., Collins, C. T., & Crowther, C. A. (2011). Aromatherapy for pain management in labour. Cochrane Database of Systematic Reviews, (7) Smith, V. C. (2012). Reluctance of women to respond to preterm labor symptoms, International Journal of Childbirth Education, 27(2), 51-56. Tillett, J. & Ames, D. (2010). The uses of aromatherapy in women�s health, Journal of Perinatal Neonatal Nursing, 24(3), 238-245. Tiran, D. (2011). Smell�s good! aromatherapy in midwifery. Practising Midwife, 14(10), 11-15. Toda, M., & Morimoto, K. (2011). Evaluation of effects of lavender and peppermint aromatherapy using sensitive salivary endocrinological stress markers. Stress & Health: Journal of the International Society for the Investigation of Stress, 27(5), 430-435. doi:10.1002/smi.1402 Tohidpour, A., Sattari, M. Omidbaigi, R. et al. (2010). Antibacterial effects of essential oils from two medicinal plants against Methicillin-resistant Staphylococcus aureus (MRSA). Phytomedicine, 17, 142-145. Wray, J. (2011). Aromatherapy for pain management in labour. Julie Wray continues our series. Practising Midwife, 14(10), 42-43. A childbirth educator for 24 years and longtime gardener of herbs and perennials, Virginia�s interest in the practical uses of aromatherapy includes first aid as well as use as a comfort measure during the childbearing year and throughout life. ICEA Approved Workshops Need certification? ICEA has approved a number of workshops for childbirth educators, doulas, nurses, etc. Please visit the link below and sign up to get your certifications today. http://icea.org/content/icea-approved-workshops 30 | International Journal of Childbirth Education | Volume 27 Number 3 July 2012 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Journal of Surgery 2015; 3(2-1): 8-13 Published online April 20, 2015 (http://www.sciencepublishinggroup.com/j/js) doi: 10.11648/j.js.s.2015030201.12 ISSN: 2330-0914 (Print); ISSN: 2330-0930 (Online) Effectiveness of Aromatherapy with Lavender Oil in Relieving Post Caesarean Incision Pain Mohamed Abdel-Hamed Metawie1, Hadayat AbdEl-Raof Amasha2, Ragaa Ali Abdraboo3, Sally Ebrahim Ali4 1Dean of Faculty of Medicine, Port-Said University, Port-Said, Egypt 2Gynecological & Obstetrical Nursing, Faculty of Nursing, Port Said University, Port-Said, Egypt 3Faculty of Nursing, Cairo University, Cairo, Egypt 4Governmental Hospital, El-Manzala, Egypt Email address:
[email protected] (M. Abdel-Hamed Metawie) To cite this article: Mohamed Abdel-Hamed Metawie, Hadayat AbdEl-Raof Amasha, Ragaa Ali Abdraboo, Sally Ebrahim Ali. Effectiveness of Aromatherapy with Lavender Oil in Relieving Post Caesarean Incision Pain. Journal of Surgery. Special Issue: Postoperative Pain Syndrome. Vol. 3, No. 2-1, 2015, pp. 8-13. doi: 10.11648/j.js.s.2015030201.12 Abstract: Background: Post caesarean section pain is a common cause of pain in obstetrics, safe pain control methods after caesarean section is a greater challenge for health care providers because the spread use of drugs can cause side effects. Non- pharmacological measures are safer with fewer side effects than pharmacological measures. Aim: The aim of the current study was to evaluate the effectiveness of aromatherapy with lavender oil in relieving post caesarean incision pain. Design: A quasi- experimental design comprising two groups was used, with a sample of convenience of 100 post caesarean section mothers. The study was conducted at the postpartum unit in Suez Canal University Hospital, Ismailia City, Egypt between October 2013 and January 2014. Fifty mothers comprising the experimental group were inhaled 1 cc of lavender essential oil via an oxygen facemask and used for three minutes, while fifty participants of the control group were given placebo then the pain level was assessed after half an hour using Visual Analogue Scale (VAS) and Modified Johanson Pain-O-Meter (MJPOM). Results of the study showed that, aromatherapy with lavender oil via oxygen facemask effectively relieving post caesarian incision pain, and highly statistically significant differences in pain intensity between the groups understudy (p< 0.001) was observed. Conclusion: Lavender oil is a successful relieving pain after caesarean section. Therefore, hospital staff managers are encouraged to establish standards of aromatherapy care in maternity department and add aromatherapy concepts and techniques in the continued training program of nurses and midwives. Keywords: Aromatherapy, Caesarean Section, Lavender Oil, Pain 1. Introduction Caesarean section (CS) is the most common operation all over the world, the rate of this operation reaches near 50% of all types of deliveries (1). Pain is a major problem in surgery, including post cesarean section pain and pain relief and patient satisfaction are still inadequate in many cases (2) . Pain can make the recovery difficult and delays mothers to get in touch with the newborns, besides being an obstacle to a good breastfeeding position, self-care, newborn care, and to do daily activities (3). Therefore, relieving post caesarean pain is an issue that cannot be ignored. Non-pharmacological methods increased the individual control feeling, decreased the feeling of weakness, improved the activity level and functional capacity, and reduced the needed dosage of analgesic drugs thus decreasing the side effects of the treatment (4). In recent years, many complementary therapies such as herbal medicines and aromatherapy are tried to help manage pain (5) . Aromatherapy is one of the non-pharmacological methods for pain relief and lavender has analgesic properties. However, lavender oil is commonly used in aromatherapy that the scent of the essential oil from the flowers is inhaled (6). Lavender oil used to alleviate pain in different conditions such as changing dressings, palliative care, to control labor pain as well as chronic pain (7). Some researchers concluded Journal of Surgery 2015; 3(2-1): 8-13 that aromatherapy by using lavender essence is effective in reducing pain after caesarean section (8) , as inhaled lavender (9) (10,11) essence and massage with lavender oil . 2. Methods 2.1. Design A quasi-experimental design was used in the current study. This study was conducted at Postpartum Unit affiliated to Suez-Canal University Hospital, Egypt. The hospital introduces teaching facilities and provides maternal and child services around the clock, free charge. 2.2. Subjects A sample of convenience of 100 mothers post CS, were selected and assigned into two groups: group I was the study group consisted of 50 mothers; and group II was the control group consisted of 50 mothers. Both study and control groups were selected according to the following inclusion criteria: age from 21 � 35 years old, full term, after six hours of operation, spinal anesthesia and not suffering from medical and/or gynecological health problems. 2.3. Data Collection Instruments Based on related literature review; the researchers used three data collection tools related to socio-demographic, history of current pregnancy, and pain assessment. Questions regarding the socio-demographic data included mothers' age, educational level, occupation, and their residence. History of current pregnancy include weeks of gestation, parity and gravidity. Other variables included antenatal care and question regarding the wanted and unwanted pregnancy. Visual Analog pain Scale (VAS) was used to assess the degree of pain, and a Modified Version of Johansson Pain-O- Meter (MJPOM) (1996) to measure the intensity of sensory and affective components of pain (12) . 2.4. Procedure of the Study The study proceeded as follows: before carrying out the lavender oil implementation, the 4th author (Ali S.E) made sure that each mother met the inclusion criteria, and willingly agreed to the participate. The researcher explained briefly the aim of the study and the procedure to the participants and taught them how to report their degree of pain using the VAS. The mothers took the routine treatment of the hospital as post CS pain relief measures, and after six hours (when the anesthesia had fully worn off), a researcher gave the experimental group 1 cc of lavender oil (applied with a cotton swab to the inside of an O2 face mask and used for three minutes). In addition, the researcher gave oxygen through a face mask with the placebo for three minutes to mothers in control group. The researcher evaluated the pain after half an hour, using VAS and MJPOM, for the two groups. Finally, the researchers coded and transformed the row data into coding sheets and then, analysis and interpretation of the collected data were done. Three days per week were specified for data collection (Sunday, Tuesday & Thursday) over a period of data of four months from the beginning of October 2013 tell ending of January 2014). 2.5. Ethical Considerations Approval was obtained from the Dean of Faculty of Nursing at Port Said University and directors of Suez Canal University Hospital. The purpose of the study was explained to each mother and an informed consent was obtained from each of those who agreed to participate. They were assured about confidentiality and privacy and that this information will be used only for research purposes. 2.6. Statistical Analysis of Data Data entry was done using Epi-Info 6.04 computer software package, while statistical analysis was done using the statistical package for social sciences (SPSS), version 15.0. Data were presented using descriptive statistics in the form of frequencies and percentages for qualitative variables, means and standard deviations for quantitative variables. Qualitative variables were compared using Chi square test (c2) as the test of significance, the p-value is the degree of significance, and the correlation (r) test was used. A significant level value was considered when p-value = 0.05, while a highly significant level value was considered when p- value = 0.001, and p-value > 0.05 indicates non-significant results. 2.7. Operational Definition Aromatherapy: The essential lavender oil of the experimental group is pure plant oil, bought from Zamzam factory established under the supervision of the Ministry of Health, Egypt (No. 108/ 2008). Incision pain: Refers to the mother's subjective pain self- report and pain observation by Visual Analogue Scale (VAS), it was developed by Melzack and Katz (1999) (12) . It comprises 10 points numerical scale, corresponding to the degree of pain, where zero indicates no pain, 10 indicates the worst pain. Modified Version of Johansson Pain-O-Meter (MJPOM), was developed by Johansson, (1996) (13) . It was used to measure the intensity of sensory and affective components of pain, where the mother's choice of words is calculated to determine pain intensity. One up to three indicates mild pain, four up to six indicate moderate pain, and seven up to nine indicate severe pain and finally, 10 indicates the worst pain. 3. Results The mean age of the study group was 27.22 � 4.4, years and that of the control group was 26.2 � 3.8 years. Figure 2 illustrates that 32.0% of the study group and 30% of the control group were illiterate. Meanwhile, only 6.0 of the study group and few percent (2.0%) of the control group graduated from university. 10 Mohamed Abdel-Hamed Metawie et al.: Effectiveness of Aromatherapy with Lavender Oil in Relieving Post Caesarean Incision Pain Fig. (1). Distribution of the study and control groups according to their age (n=100). Fig. (2). Distribution of the study and control groups according to their educational level (n=100). As regards post-cesarean incision pain intensity measured control group; 2.0% of the study group had experienced the by visual analogue scale (VAS), the results reveal that, 16.0% worst pain, while 28.0% of the control group had experienced of the study group had experienced mild pain compared to the worst pain. A highly statistically significant difference was none of the control group. Seventy percent of the study group found between both groups (p<0.001) (table 1). had experienced moderate pain compared to 18.0% of the 2 Mohamed Abdel-Hamed Metawie et al.: Effectiveness of Aromatherapy with Lavender Oil in Relieving Post Caesarean Incision Pain Table 1. Distribution of the study and control groups according to their incision pain level as recorded by the Visual Analogue Scale (VAS) & Modified Version of Johansson Pain-O-Meter MJPOM (n=100). Study Group (n=50) Control Group (n=50) Items . cccc2 2222 P value No (%) No (%) Incision Pain Level by VAS Mild Moderate Severe Very severe Worst Incision Pain Level by MJPOM Mild Moderate Severe Very severe Worst 8 (16.0) 35 (70.0) 6 (12.0) 0 (0.0) 1 (2.0) 0 (0.0) 18 (36.0) 17 (34.0) 11 (22.0) 4 (08.0) 0 (0.0) 9 (18.0) 11 (22.0) 52.10 <0.001** 16 (32.0) 14 (28.0) 0 (0.0) 1(2.0) 0 (0.0) 50.97 <0.001** 29 (58.0) 20 (40.0) ** Significant at p-value<0.001 The same table shows distribution of pain intensity among both study and control groups as recorded by the Modified version of Johansson Pain-O-Meter (MJPOM). No one of both groups had reported mild pain, 36.0% of the study group had reported moderate pain compared to 2.0% of the control group, 34.0% of the study group had reported severe pain. While none of the control group reported severe pain, 22.0% of the study group reported very severe pain, versus 58.0% of the control group and 8.0% of the study group reported the worst pain compared to 40.0% of the control group reported the worst pain. A highly statistically significant difference was found between both groups (p<0.001). It was noticed from table 2 that an 8% of the study group compared with 24.0% of the control group described their pain by the word "cutting", while 6.0% of the control group versus 2.0% of the study group described, their pain by the word "burning", a lesser percentage 2.0% of the control group described their pain by the word "cramping versus none of the study group. On the other hand, more than third of the control group (38.0%) compared to 60.0% of the study group described their pain by the word "gnawing". Only 4.0% of the study group described their pain by the word "pinching", versus more of the control group, and 22.0% of the study group versus none of the control group described their pain by the word "stinging". A highly statistically significant difference was found between both groups in relation to pain intensity (p<0.001). Table 2. Distribution of the study and control groups according to their incision pain intensity as recorded by the Modified Version of Johansson Pain-O-Meter (MJPOM) (n=100) Items Study group (n=50) Control group (n=50) . cccc 2 2222 P-value No % No % Sensory Pain Cutting 4 8.0 12 24.0 Tearing 0 0.0 0 0.0 Sharp 0 0.0 3 6.0 Burning 1 2.0 3 6.0 Cramping 0 0.0 1 2.0 Pressing 0 0.0 11 22.0 35.80 <0.001** Aching 2 4.0 1 2.0 Gnawing 30 60.0 19 38.0 Pinching 2 4.0 0 0.0 Stinging 11 22.0 0 0.0 Sore 0 0.0 0 0.0 Affective Pain Torturing 4 8.0 12 24.0 Killing 0 0.0 0 0.0 Suffocating 0 0.0 3 6.0 Terrifying 1 2.0 3 6.0 Dreadful 0 0.0 1 2.0 35.80 <0.001** Fearful 0 0.0 11 22.0 Troublesome 2 4.0 1 2.0 Tiring 30 60.0 19 38.0 Irritating 2 4.0 0 0.0 Nagging 11 22.0 0 0.0 ** Significant at p -value<0.001 2 Mohamed Abdel-Hamed Metawie et al.: Effectiveness of Aromatherapy with Lavender Oil in Relieving Post Caesarean Incision Pain The same table indicates that the word "tiring" was the most frequently used as an affective pain descriptor between the two groups (study, 60.0% & control, 38.0%). However, the word "killing" was not used as an affective pain descriptor between the two groups. A highly statistically significant difference also was found between both groups in relation to pain intensity recorded (p<0.001). Table 3 shows that there was a statistically significant relation between the effect of lavender oil and educational level (p < 0.05). Lavender oil was more effective between educated mothers rather than non-educated ones. The same table shows relation between pain intensity according to the visual analogue scale and parity. A highly statistically significant difference was found between the effect of lavender oil and parity (p <0.001), lavender oil was more effective with multiparous than primiparous. However, there was no statistically significant relation between the others selected variables (antenatal care & wanted pregnancy) and lavender oil inhalation post CS (p= >0.05 & 0.05 respectively). Table 3. Relation between pain intensity according to the visual analogue scale and selected variables to the study group (n=50). p-value . . Pain Level Selected Variables Mild Moderate Severe Very Severe Worst N (%) N (%) N (%) N (%) N (%) Education 16.29. <0.05* Non-educated (n=16) 1(6.3) 12(75.0) 3(18.8) 0(0.0) 1(6.3) Educated (n=34) 7(20.6) 23(67.6) 3(8.8) 0(0.0) 0(0.0) Parity 38.34 <0.001** Para1(n=8) 0(0.0) 2.0(25.0) 5(62.3) 0(0.0) 1(12.5) Para 2 (n=11) 0(0.0) 10(90.0) 1(9.1) 0(0.0) 0(0.0) Para 3 or more (n=31) 8(25.8) 23(74.8) 0(0.0) 0(0.0) 0(0.0) Antenatal care 1.70 >0.05 Yes (n=42) 5(11.9) 32(76.2) 4(9.5) 0(0.0) 1(2.4) No (n=8) 3(37.5) 3(37.5) 2(25.0) 0(0.0) 0(0.0) Wanted pregnancy 5.67 >0.05 Yes (n=34) 5(14.7) 26(76.5) 2(5.9) 0(0.0) 1(2.9) No (n=16) 3(18.8) 9(56.3) 4(25.0) 0(0.0) 0(0.0) * Significance at <0.05 Table 4. Correlation between Visual Analogue Scale score and Modified version of Johansson Pain-O-Meter (MJPOM) Variables Modified version of Johansson Pain-O-Meter (JPOM) r p- value Visual Analogue Scale .522(**) .000 ** Correlation is significant at the 0.01 level (2-tailed). Table 4 shows that there was a positive correlation between Visual Analogue Scale and Modified version of Johansson Pain-O-Meter (r= .522 at p= .000). 4. Discussion The pain control after cesarean delivery is a great challenge for the health care provider because the spread use of drugs can cause side effects such as; nausea, vomiting and excessive sedation; and it can cause a delay in getting out of bed and discharge from the hospital. In addition, the drugs excrete in breast milk and can cause sedation in baby as well (14). Pollard (2008) (15), observed that the use of aromatherapy reduced the need for more invasive forms of pain management and has a positive effect on client satisfaction. Side effects of the oils were documented in only two cases (1%); these side effects were skin irritation and headache. No adverse reactions were documented with regard to babies born in the birthing pool. The result of current study goes in line with other studies stated that there was a significant reduction in pain level of postoperative cesarean section after inhaling lavender essence (16,17) ,on episiotomy pain using lavender oil bath at four hours and five days after delivery (18,19) . The current study was in accordance with other studies reporting analgesic effect of lavender oil and decreased the number of required analgesics following tonsillectomy in pediatric patients (20) and found that aromatherapy with lavender oil a good alternative to reduce normal labour pain and is more effective than breathing techniques (21). Our data was also consistent with others of same interest who reported that aromatherapy with inhalation lavender essential oil is effective on anxiety and pain in IUD insertion(22) and in reducing pain following needle insertion into a fistula in hemodialysis patients (9). 5. Conclusion In the light of the findings of the current study, it can be concluded that, lavender oil was an effective method in postoperative pain control with comparison to placebo treatment. Lavender oil inhalation appears to be an effective non-invasive and non-pharmacological intervention for postoperative pain management. The efficiency of intervention is 2 Mohamed Abdel-Hamed Metawie et al.: Effectiveness of Aromatherapy with Lavender Oil in Relieving Post Caesarean Incision Pain found to be effective in pain reduction after 30 minutes, in relation to lavender oil inhalation it can be used as an effective nursing initiative in post cesarean section pain control. Recommendations Based on the findings and conclusion, the following recommendations can be suggested. � Hospital managers are encouraged to include aromatherapy techniques in the training program for maternity nurses and recommended to be included in the hospital protocol for management of post-cesarean incision pain. � Lavender oil inhalation for relieving post cesarean pain may be added in maternal nursing curricula of nursing schools. References [1] Ganji, F., Yusefi, H., & Baradaran, A. Effect of a participatory intervention to reduce the number of unnecessary cesarean sections performed in Shahrekord of Iran. J. Medical Sci; 2006; 6, 690-692. [2] Stourac P, Kucharov� E, Krikava I, Mal� R, Kosinov� M, Harazim H, Sm�kalov� O, B�rt�kov� I, Stoudek R, Janku P, Huser M, W�gnerov� K, Haklov� O, Hakl L, Schwarz D, Zelinkov� H, Littnerov� S, Jarkovsk� J, G�l R, Sevc�k P. Establishment and evaluation of a post caesarean acute pain service in a perinatological center:retrospective observational study. Ceska Gynekol. 2014 Fall;79(5):363-370 [3] Granot, M., Lowenstein, L., Yarnitsky, D., Tamir, A., & Zimmer, E.Z. Post cesarean section pain prediction by preoperative experimental pain assessment. Anesthesiol; 2004; 98(6), 1422-6. [4] Yildirim, G., & Sahin, N.H. The effect of breathing and skin stimulation on labour pain perception of Turkish women. Pain Research & Management; 2004; 9(4), 183-7. [5] Smith, C.A., Collins, C.T., Cyna, A.M., & Crowther, C.A. Complementary and alternative therapies for pain management in Labour. Cochrane Database of Systematic Reviews; 2006;18(4), CD003521. [6] Marzouk T, Barakat R, Ragab A, Badria F, Badawy A. Lavender-thymol as a new topical aromatherapy preparation for episiotomy: A randomised clinical trial. J Obstet Gynaecol. 2014 ; 10:1-4. [7] Kim, J.T., Wajda, M., Cuff, G., Serota, D., Schlame, M., Axelrod, D.M., Guth, A.A., & Bekker, A.Y. (2006). Evaluation of aromatherapy in treating postoperative pain: Pilot study. World Institute of Pain Practice; 2006; 6 (4), 273277. [8] Hadi, N., & Hanid, A.A. Lavender essence for post cesarean pain. Pakistan J Biolo Sci; 2011; 14(11), 664.667. [9] Nesami, M.B., Espahbodi, F., Nikkhah, A., Shorofi, S.A., & Charati, J.Y. The effects of lavender aromatherapy on pain following needle insertion into a fistula in hemodialysis patients. Complement Ther Clin Pract. 2014 ;20(1):1-4 [10] Zahra, A., & Leila, M.S. Lavender aromatherapy massages in reducing labor pain and duration of labor: A randomized controlled trial. African Journal of Pharmacy and Pharmacology; 2013; 7(8), 426-430. [11] Henry, A., & Nand, S., Intrapartum pain management at the Royal Hospital for Women: Australia and New Zealand Journal of Obstetrics and Gynecology, 2004; 44(4):307-317. [12] Melzack R, Katz J. Measurement of pain. Surg Clin North Am 1999; 79:231-252. [13] Gaston-Johansson F. Measurement of pain: the psychometric properties of the Pain-O-meter, a simple inexpensive pain assessment tool that could change health care practices. J Pain and Symptom Management 1996; 12 (3), 172�181. [14] Fr�guls B1, Joya X, Garc�a-Algar O, Pall�s CR, Vall O, Pichini S. A comprehensive review of assay methods to determine drugs in breast milk and the safety of breastfeeding when taking drugs. Anal Bioanal Chem. 2010 Jun;397(3):1157-79 [15] Pollard, K.R. Introducing aromatherapy as a form of pain management into a delivery suite. Journal of the Association of Chartered Physiotherapists in Women�s Health; 2008; 103, 12�16. [16] Sobhani, A., Sharemi, H., Orangpur, R., Shokuhi, F., & Oudi, M. Effect of lavender oil in cesarian pain relief. J Gilan Univ Med Sci; 2007; 16(62), 80-86. [17] Olapour, A., Behaeen, K., Akhondzadeh, R., Soltani, F., Razavi, S.F., & Bekhradi, R. The effect of inhalation of aromatherapy blend containing Lavender essential oil on cesarean postoperative pain. Anesthesiol Pain Med; 2013; 3(1), 203-7. [18] Sheikhan, F., Jahdi, F., Khoei, E.M., Shamsalizadeh, N., Sheikhan, M., & Haghani, H. Episiotomy pain relief: Use of Lavender oil essence in primiparous Iranian women. Complement Ther Clin Pract. 2012 Feb;18(1):66-70 [19] Masoumi, Z., Keramat, A., & Hajiaghaee, R. Systemic review on effect of herbal medicine on pain after perineal episiotomy and cesarean cutting. J Med Plants;2011; 4(40), 1-6. [20] Soltani, R., Soheilipour, S., Hajhashemi, V., Asghari, G., Bagheri, M., & Molavi, M. Evaluation of the effect of aromatherapy with lavender essential oil on post- tonsillectomy pain in pediatric patients: A Randomized Controlled Trial; Int J Pediatr Otorhinolaryngol. 2013 Sep;77(9):1579-81 [21] Seraji, A., & Vakilian, K. The comparison between the effects of aromatherapy with lavender and breathing techniques on the reduction of labor pain. Complement Med; 2011; 1(1), 31-39 [22] Shahnazi M, Nikjoo R, Yavarikia P, Mohammad-Alizadeh- Charandabi S. Inhaled lavender effect on anxiety and pain caused from intrauterine device insertion. J Caring Sci. 2012 Nov 28;1(4):255-61. The Effect of Inhalation of Aromatherapy Blend containing Lavender Essential Oil on Cesarean Postoperative Pain Alireza Olapour 1, Kaveh Behaeen 1, Reza Akhondzadeh 1, Farhad Soltani 1, Forough al Sadat Razavi 1, *, Reza Bekhradi 2 1 Department of Anesthesiology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran 2 Barij Essence Research and Development Centre, Kashan, Iran *Corresponding author: Forough al Sadat Razavi, Department of Anesthesiology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Tel: +98-6113743037, Fax: +98-6113743037, E-mail:
[email protected]. ABSTRACT Background: Pain is a major problem in patients after cesarean and medication such as aromatherapy which is a complementary therapy, in which the essences of the plants oils are used to reduce such undesirable conditions.Objectives: In this study, the effect of aromatherapy using Lavender (Lavandula) essential oil on cesarean postoperative pain was assessed. Materials and Methods: In a triple blind, randomized placebo-controlled trial study, 60 pregnant women who were admitted to a general hospital for cesarean section, were divided randomly into two groups. After cesarean, the Lavender group inhaled about 3 drops of 10% Lavender oil essence and the placebo group inhaled 3 drops of placebo after the start of postoperative pain, four, eight and 12 hours later, for 5 minutes from the 10 cm distance. Patient's pain was measured by the VAS (Visual Analog Scale) score before and after each intervention, and vital sign, complications and level of satisfaction of every patient were recorded before and after aromatherapy.Results: There was no statistically significant difference between groups in age, height, weight, and time to the first analgesicrequirement. Patients in the Lavender group had less postoperative pain in four (P = 0.008), eight (P = 0.024) and 12 (P = 0.011) hours after first medication than the placebo group. The decreased heart rate and patients' level of satisfaction with analgesia were significantly higher in the Lavender group (P = 0.001). In the placebo group, the use of diclofenac suppositories for complete analgesia was also significantly higher than the Lavender group (P = 0.008).Conclusions: The inhaled Lavender essence may be used as a part of the multidisciplinary treatment of pain after cesarean section, but it is not recommended as the sole pain management. Keywords: Pregnant Women; Aromatherapy; Lavandula; Cesarean Section; Pain Copyright � 2013, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM); Published by Kowsar Corp. .Article type: Research Article; Received: 22 Dec 2012, Revised: 16 Jan 2013, Accepted: 26 Jan 2013; Epub: 01 Jul 2013; DOI: 10.5812/ aapm.9570 .Implication for health policy/practice/research/medical education: The addition of inhalation aromatherapy using lavender essence oil to the pain control protocol, which includes NSAIDs and opioids, may decrease the side effects of such drugs and also may decrease treatment costs of cesarean postoperative pain for patients and decision makers and experts in the health sector. .Please cite this paper as: Olapour A, Behaeen K, Akhondzadeh R, Soltani F, al Sadat Razavi F, Bekhradi R. The Effect of Inhalation of Aromatherapy Blend containing Lavender Essential Oil on Cesarean Postoperative Pain. Anesth Pain. 2013;3(1):203- 7. DOI: 10.5812/aapm.9570 .Copyright � 2013, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM); Published by Kowsar Corp. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Background Pain is amongst the most common problems after surgery (1). Pain is an unpleasant sensory and emotional experience, which is associated with the real or probablydamage of tissue. Unrelieved postoperative pain in addition to creating fears in the surgical patients, it makesadverse psychological impact on them (2, 3). The uncontrolled postoperative pain will make a lot of acute and chronic effects, including systemic mediators, hypercoagulability, postoperative immunosuppression, and delayed wound healing (4). So, one of the main aims of anesthesia is to reduce postoperative pain. However, many drugs that are used for this purpose, especially opioidsand NSAIDs (None Steroidal Anti Inflammatory Drugs), have side effects such as respiratory distress, nausea, itching, and gastrointestinal bleeding (5). Recent studieshave indicated interest in using complementary therapies such as heat and cold therapy, hypnotism, music therapy and aromatherapy. Aromatherapy is used for the relief of pain, anxiety, depression, insomnia and fatigue, using the existing oils in different parts of the plant such as Lavandula angustifolia (6-11). Lavandula is a flowering plant from the Lamiaceae family, native to the western Mediterranean region. The lipophilic monoterpenes atthe plant are reacted to the cell membranes, and cause changes in the activity of ion channels, carriers and nervous receptors. Such property can explain the soothingand anti-bacterial effects of Lavender oil (12). 2. Objectives Cesarean surgery is common, especially in our country, and the patient's postoperative pain is a serious problem. Furthermore, the extent of conventional method for the pain relief is a prescription of opioids and NSAIDs, which are also associated with certain complications, and needsadditional methods of the pain control, consequently, we decided to assess the effect of the inhalation aromatherapy using Lavender oil essence on postoperative pain. 3. Materials and Methods In a triple blind, randomized placebo-controlled trial,which was performed for the first time in Ahvaz, a city located in the south western part of Iran, after approving by Ahvaz Jundishapur University of Medical Sciences (AJUMS) Ethical Committee, 60 pregnant women, whowere admitted to a general hospital for cesarean section,were divided randomly into two groups. Subjects with pregnancy, ASA class I and II, absence of hypertension, coagulation disorders, migraines and chronic headaches,no history of allergies to medicinal plants, no history of anosmia were included. Subjects with respiratory problems during surgery, nausea, vomiting, sensitivity and dissatisfaction after the first dose of aromatherapy using Lavender oil essence were excluded. The severity of pain was documented based on the Visual Analog Scale (VAS).The VAS is a standard tool like a 10 cm ruler including 10 numbers begin from 0 (no pain) and end to 10 (most severe pain). Different states of a human face in response to pain severity have been plotted on the other side of ruler. The patients were asked to choose one of them according to their pain severity. The number shown on the back of the ruler was considered as pain score. The Lavenders (Lavandula angustifolia) are a genus of several species of flowering plants in the mint family, Lamiaceae. In this study, Lavender essence 10% was provided by the Barij Essence Pharmaceudical Company (Kashan,Iran). Placebo was a base of aromatherapy blend without Lavender essence which was provided by the Barij Essence Pharmaceudical Company too. In the beginning, possible side effects of drugs used in the study, were explained to the patients, and after obtaining informedconsent, patients were entered into the operating room. Patients were performed monitoring by ECG (Electrocardiography), monitoring for heart rate recording, NIBP(None Invasive Blood Pressure) and Pulseoximetry. After embedding the peripheral intravenous cannula, 500 cc of Ringer's crystalloid fluid was infused for patients. Afterwards, regional block with spinal anesthesia was performed with 60 mg of Lidocaine 5%, and then the patients underwent cesarean section. Opioid or benzodiazepine was not used after cesarean section in operating room assedation. Pain score were measured using the VAS score for all patients. After the onset of postoperative pain (if VAS > 3), four, eight and 12 hours after that, the inhalation aromatherapy was performed using Lavender essence. In one group, three drops of aromatherapy blend containing Lavender essence 10% (provided by The Barij Essence Pharmaceutical Compnay) were poured on cotton incast containers, and the patient was asked to inhale itfor 5 minutes from a distance of 10 cm; and pain score was measured using the VAS again, and if the VAS was greater than three, analgesic was given in accordance with the hospital routine protocol (the first time, intramuscular injection of Diclofenac sodume 75 mg and next times, Diclofenac suppositories 100 mg). Using the sameprocedure, aromatherapy was performed in the othergroup by three drops of placebo (a base of aromatherapy blend without Lavender essence) where its smell and appearance were similar to the Lavender oil essence. Heart rate, blood pressure, nausea, vomiting, dizziness, andpatient's satisfaction were recorded before and after the aromatherapy based on the questionnaire. During theresearch, the project executive and the patients were notaware of the type of drug and placebo, and after the study and data analysis, the Lavender and the placebo were disclosed by the Barij Essence Pharmaceudical Company. All data were analyzed using the SPSS for Windows (version19.0). Independent T-test was used compare the meanpain in two groups; the Paired t- test was used to comparethe pain before and after intervention. The significance level was set to P = 0.05. 4. Results In this study, all patients were ASA class I. At the time of the onset of the pain after cesarean section, aromatherapy with Lavender essence was performed. Average age, height, weight in the two groups showed no significantdifference, and times of need to the first analgesic from cesarean section were similar in the two groups (Table 1). After using the drug comparing it with before, therewas more decrease in the VAS score in the Lavender group than the placebo group, these values were significant in four, eight and 12 hours after the first intervention (Table Table 1. Baseline Charactristics of Patients 2). In the Lavender group, the level of satisfaction from the drug was 90 %, while in the placebo group, a 50% satisfaction was reported (P = 0.001) (Figure 1). In the Lavender group, using Diclofenac suppository for completing analgesia was 43.3%, and in the placebo group was 76.7% (P =0.008) (Figure 2). After using the drug comparing it with before, heart rateshowed a greater reduction in the Lavender group compared with the placebo group, which has been shown in the table (Table 3). However, no difference was observed in terms of the blood pressure between the two groups. In terms of the complication incidence, only one patient in the placebo group had nausea, and none of the patients in both groups had vomiting and dizziness. Lavender group, Mean � SD Placebo group, Mean � SD P value Age, y 27.83 � 5.65 25.57 � 4.11 0.96 Height, cm 159.57 � 4.15 158.7 � 4.41 0.78 Weight, kg 79.57 � 8.99 76.07 � 9.35 0.78 Time of first request of analgesia after Spinal anesthesia 98.83 � 9.16 98.33 � 9.67 0.72 Table 2. Comparison of the VAS in Two Groups Lavender group, Mean � SD Placebo group, Mean � SD P value Pain reduction after medication for the first time 0.23 � 0.43 0.27 � 0.64 0.353 Pain reduction 4 hours after medication for the first time 1.37 � 0.89 0.5 � 0.57 0.008 Pain reduction 8 hours after medication for the first time 1.63 � 0.89 0.4 � 0.49 0.024 Pain reduction 12 hours after medication for the first time 1.40 � 0.62 0.2 � 0.48 0.011 Table 3. Comparison of Heart Rate in Two Groups Lavender group, Mean � SD Placebo group, Mean � SD P value Pain reduction after medication for the first time 4.83 � 5.96 0.63 � 2.45 < 0.001 Pain reduction 4 hours after medication for the first time 3.30 � 4.60 0.77 � 4.24 0.439 Pain reduction 8 hours after medication for the first time 4.30 � 5.62 0 � 3.16 0.016 Pain reduction 12 hours after medication for the first time 2.2 � 2.82 0.57 � 2.23 0.798 5. Discussion This study investigated the effect of inhaled Lavender essence on the pain relief after cesarean. The results showed that pain after surgery in four, eight and 12 hours after the onset of symptoms following inhalation of Lavender essence have had a significant decrease compared with the placebo group. The pain control after cesarean delivery is a great challenge for the anesthesiologists and gynecologists, because the spread use of drugs can cause side effects such as nausea, vomiting and excessivesedation; and it can cause a delay in getting out of bed and discharge from the hospital. In addition, the drugsexcrete in breast milk and can cause sedation in baby as well (13). The use of non-opioid analgesics and alternative treatment alone has failed to establish an effective and satisfactory analgesia for patients. It seems necessary to use multiple methods of analgesia (multi-modal) for the pain relief after Cesarean section and to have more research in this area (4). The effects of various forms of Lavender essence on postoperative pain control have been investigated in the previous studies. In a study performed by Sobhani and Colleagues in 2004 in Rasht cityon pain relief after cesarean section, in each three stages of the intervention (in which its first stage was performed six hours after the onset of the pain) there was a significant reduction in pain after inhaling Lavender essence. These results are similar to our study except that: 1) in the mentioned study, intervention was not immediately performed after the onset of the pain and 2) we used Lavender essence 10% (14). Figure 1. The Satisfaction From Using Drug in Two Groups Figure 2. Frequency of Patients need to Take Diclofenac Suppositories to Complete Pre-Operative Analgesia In a study on women undergoing elective cesareansection performed in Tabriz city, an important reduction was seen in pain at half, eight and 16 hours afterintervention in the group using inhaled Lavender, while in our study, there was no significant difference between the two groups at the first intervention at the onset of the pain unlike for the four, eight and 12 hours. Also in our study, the Lavender essence 10% was used (6). In a study performed by Sheikhan and Colleagues on episiotomy pain using Lavender bath extract, pain in the Lavender group at four hours and also five days after delivery was significantly reduced (9). Moreover, in a similar study conducted by Ailsa also using Lavender oil bath for 10 days after vaginal delivery, the slight reduction of pain, though significant, was seen in the Lavender group compared to the control group (15). Furthermore, in Khadivzadeh's study in which Lavender cream has been used to relieve episiotomy pain, the pain on days three, five and 10 afterbirth was significantly reduced compared to the controlgroup, but this difference was not significant in the first 24 hours of the delivery (16). We found that Diclofenac suppository dosage as a supplemental analgesic drug in the Lavender group was significantly lower than the placebo group. These findings are similar to a study by Jung TK on patients who underwent laparoscopic gastricbanding surgery. But in our study the Lavender essence 10% was used. In that study, despite the decrease of pain, the score was not significantly different in the two groups, but morphine consumption was decreased significantlyin the Lavender group (17). In the present study, patient's satisfaction with supplemental analgesia techniqueswas considered, and it showed that satisfaction withtreatment in the Lavender group was significantly higher than the placebo group. This satisfaction has also been reported in two previous studies, which wereconducted on obese patients undergoing laparoscopic adjustable gastric banding and patients undergoingbreast biopsy surgery with the difference that we used Lavender essence 10% (17, 18). Also, in a study conducted by Mohammadkhani on postpartum perineal pain,patients receiving Lavender were more satisfied than controls (19). Due to the lack of reported side effects such as nausea, vomiting and dizziness in the group treatedwith Lavandula in our study and other studies on this drug, it can be concluded that this drug doesnot have serious and common side effects of the opioid analgesics and NSAIDs, and further studies could be used as part ofa multimodal analgesic treatment of postoperative pain. Based on findings of our study, it can be concluded that the inhaled Lavender essence may be used as a part of the multimodal analgesic treatment after cesarean section,but it is not recommended using the sole analgesic treatment. Acknowledgements This research is a result of residential thesis (Ref No:U90291). Hereby, we acknowledge deputy vice-chancellor for research and technology affairs of AhvazJundishapur University of Medical Sciences, especiallyResearch Consultation Center (RCC) for technical support. Authors� Contribution Study concept and design: Olapour, Behaeen and Raza vi. Analysis and interpretation of data: Olapour, Behaeen and Bekhradi. Drafting of the manuscript: Akhondzadeh, Soltani and Razavi. Collection and possession of raw data: Razavi. Critical revision: Behaeen, Akhondzadeh and Razavi. Financial Disclosure The authors declare they have no financial disclosure. Funding/Support Ahvaz Jundishapur University of Medical Sciences, Vice Chancellor for Research and Technology. Trial Registration: www.irct.ir Identifier: IRCT201204249552N1. References 1. McQuay H, Derry S, Wiffen P, Moore A, Eccleston C. Postoperative pain management: Number-needed-to-treat approachversus procedure-specific pain management approach. Pain. 2012;154(1):180 2. Ochroch EA, Gottschalk A. Impact of acute pain and its management for thoracic surgical patients. Thorac Surg Clin.2005;15(1):105-21 3. Pritchard MJ. Managing anxiety in the elective surgical patient.Br J Nurs. 2009;18(7):416-9 4. Hurley RW, Wu ChLChap. Acute Postoperative Pain. In: Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL, editors.Miller�s Anesthesia. 7 ed. USA: Churchill Livingstone; 2010. p. 27572781 5. Gupta A, Kaur K, Sharma S, Goyal S, Arora S, Murthy RS. Clinical aspects of acute post-operative pain management & its assessment. J Adv Pharm Technol Res. 2010;1(2):97-108 6. Hadi N, Hanid AA. Lavender essence for post-cesarean pain. Pak J Biol Sci. 2011;14(11):664-7 7. Kim S, Kim HJ, Yeo JS, Hong SJ, Lee JM, Jeon Y. The effect of lavender oil on stress, bispectral index values, and needle insertion pain in volunteers. J Altern Complement Med. 2011;17(9):823-6 8. Podichetty VK, Varley ES. Re: Oleske D M, Lavender S A, Andersson G B, et al. Are back supports plus education more effective than education alone in promoting recovery from low back pain? Results from a randomized clinical trial. Spine 2007;32:2050-7. Spine (Phila Pa 1976). 2008;33(3):349-50 9. Sheikhan F, Jahdi F, Khoei EM, Shamsalizadeh N, Sheikhan M, Haghani H. Episiotomy pain relief: Use of Lavender oil essence in primiparous Iranian women. Complement Ther Clin Pract.2012;18(1):66-70 10. Yip YB, Tse SH. The effectiveness of relaxation acupoint stimulation and acupressure with aromatic lavender essential oil for non-specific low back pain in Hong Kong: a randomised controlled trial. Complement Ther Med. 2004;12(1):28-37 11. Yip YB, Tse SH. An experimental study on the effectiveness of acupressure with aromatic lavender essential oil for sub-acute, non-specific neck pain in Hong Kong. Complement Ther Clin Pract.2006;12(1):18-26 12. van Wyk BE. A broad review of commercially important southern African medicinal plants. J Ethnopharmacol. 2008;119(3):342-55 13. Fukuda K. Opioids. In: Miller RDEL, Fleisher LA, Wiener-KronishJP, Young WL, editors.Miller�s Anesthesia. USA: Churchill Living-stone; 2010. p. 769-824 14. Sobhani A, Sharemi H, Orang pur R, Shokuhi F, Oudi M. Effect of Lavender Oil in cesarian pain relief. J Gilan Univ Med Sci. 2007;16(62):80-86 15. Masoumi Z, Keramat A, Hajiaghaee R. Systemic review on effect of Herbal Medicine on pain after perineal episiotomy and cesearean cutting. J Med Plants. 2011;4(40):1-6 16. Khadivzadeh T, Molkizadeh M, Rakhshandeh M. Evaluation of lavander cream effect on episiotomy pain and wound healing in primiparous women. Int J Gynecol Obstetrics. 2009;107(Supplement 2):S498-S499 17. Kim JT, Ren CJ, Fielding GA, Pitti A, Kasumi T, Wajda M, et al. Treatment with lavender aromatherapy in the post-anesthesia care unit reduces opioid requirements of morbidly obese patients undergoing laparoscopic adjustable gastric banding. Obes Surg.2007;17(7):920-5 18. Kim JT, Wajda M, Cuff G, Serota D, Schlame M, Axelrod DM, et al. Evaluation of aromatherapy in treating postoperative pain: pilot study. Pain Pract. 2006;6(4):273-7 19. Mohammadkhani S. The effect of massage aromatherapywith Lavender oil on active phase pain intensity and satisfaction of labornullipara women. Iranian J Reproduct Med. 2009;7(Suppl 1):10-20 Iran Red Crescent Med J. 2015 April; 17(4): e25880. DOI: 10.5812/ircmj.17(4)2015.25880 Published online 2015 April 25. Research Article Lavender Fragrance Essential Oil and the Quality of Sleep in Postpartum Women 12,*2 Mahnaz Keshavarz Afshar ; Zahra Behboodi Moghadam ; Ziba Taghizadeh ; Reza Bekhradi 3; Ali Montazeri 4; Pouran Mokhtari 1 1 Department of Midwifery, School of Nursing and Midwifery, Zanjan University of Medical Sciences, Zanjan, IR Iran 2 Department of Reproductive Health, Nursing and Midwifery Faculty, Tehran University of Medical Sciences, Tehran, IR Iran 3 Research and Development Unit, Barij Essence Company, Kashan, IR Iran 4 Mental Health Research Group, Health Metrics Research Center, Iranian Institute for Health Sciences Research, ACECR, Tehran, IR Iran *Corresponding Author: Zahra Behboodi Moghadam, Department of Reproductive Health, Nursing and Midwifery Faculty, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-9122494201, Fax+98-2166927171, E-mail:
[email protected] Received: December 10, 2014; Revised: December 28, 2014; Accepted: January 11, 2015 Background: Labor and delivery is a stressful stage for mothers. During these periods, sleep-related disorders have been reported. The problems of inadequate sleep include decrease in concentration, judgment, difficulty in performing daily activities, and an increase in irritability. Even the effects of moderate sleep loss on life and health quality can be similar to sleep deprivation. some research aggravated by aromatherapy on sleep quality in different periods of life so might be useful for the improve of sleep quality in postpartum women.Objectives: This study aimed to determine the effect of aromatherapy on the quality of sleep in postpartum women. The sample was recruited from medical health centers of Zanjan University of Medical Sciences.Patients and Methods: This study was a randomized clinical trial with the control group. A total of 158 mothers in postpartum period (with certain inclusion criteria) were enrolled in the study and assigned randomly to two groups of control and intervention. Lavender fragrance (made by Barij Essence Pharmaceutical Co.) was used by participants in the intervention group nightly before sleeping. The fragrance was dropped on cotton balls, which were placed on a cylindrical container at mothers� disposal. Keeping the container at a projected distance of 20 cm, the participants inhaled 10 deep breaths and then the container was placed beside their pillow until morning. This procedure was done 4 times a week for 8 weeks. For the control group, the same intervention was done with the placebo. The instrument for collecting data was Pittsburgh sleep quality index, which was completed at the baseline, fourth, and eighth weeks after the intervention. Data were analyzed using independent t test and repeated measures analysis of variance calculated by SPSS16.Results: Before the intervention, there were no significant differences between mothers in two groups (P > 0.05). After 8 weeks follow up, a significant improvement appeared in mothers� sleep quality in the intervention group. Aromatherapy increased sleep quality mean score (�SD) from 8.2911 (� 2.1192) to 6.7975 (� 2.3663) (P < 0.05), but in the control group sleep quality mean score (�SD) changes from 8.4557 (� 2.3027) to 7.5696 (� 1.1464) (P > 0.05). Comparing sleep quality between control and intervention groups after 8 weeks from the beginning of the intervention indicated that aromatherapy was effective in the improvement of mothers� sleep quality (P < 0.05).Conclusions: Considering the effects of aromatherapy on the improvement of mother�s sleep quality during postpartum period, aromatherapy has been suggested as a non-pharmacological method for the improvement of the maternal health. Keywords: Sleep Disorders; Aromatherapy; Lavandula; Postpartum Period 1. Background Labor and delivery is a stressful stage for mothers. This stage entails a change in their life style (1). Pregnancy and postpartum are two important stages for women and their families (2). During these periods, sleep-related disorders have been reported (3). Sleep is an important process in human life. The problems of inadequate sleep include decrease in concentration, judgment, difficulty in performing daily activities, and an increase in irritability (4). Research shows that inadequate sleep affects hemostatic and nerve functions, as well as mood. Even the effects of moderate sleep loss on life and health quality can be similar to sleep deprivation. Many medical practitioners and patients are faced with such prob lems (5). Most mothers experience changes in their quality of sleep during postpartum period. According to the researches, changes in sleep duration and its patterns have normally been reported. Sleep problems are related to pain, wound discomfort, lactation, or uterine contractions (6). Mothers in postpartum period normally experience 20% increase in their wakefulness during night (7). According to the National Sleep Foundation survey in 2007, 67% of women in the postpartum period reported disturbed sleep cycles (8). In general, changes in sleep patterns during the first year after delivery is the distinctive feature of this period, which affects health and functions of mothers and Copyright � 2015, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited. Keshavarz Afshar M et al. creates a lot of problems not only for them but also for their families (9). One of the most important side effects of inadequate quality of sleep is the incident and severity of postpartum depression (3, 10). Another adverse side effect of impaired sleep patterns is the cessation of breastfeeding and decreased mother-infant attachment (11). Sleep deprivation can even decrease the growth of infant (12), and reduce mothers� immune functioning, metabolism, mood, and performance (13). For many reasons, intervention and studies of sleeping patterns after delivery are very important and sensitive for a nascent family at this time. However, studying sleep characteristics is a difficult and complicated concept, as in this period, mothers and their families try to incorporate a new member into their family (14). What mothers could do regarding the quality of sleep, its disturbance, and frequency at this crucial time is still being investigated. Physical and mental health of mothers, newborn outcomes, and maternal-infant relationship are affected by fully understanding and correct recognition of sleep during pregnancy and postpartum (3). Midwives usually train mothers to reduce fatigue and improve sleep, which most of these trainings are generally not evidence-based (14). Drug therapy is another way to improve sleep quality; however, it has many side effects and not the best way to improve sleep quality (15). Because of the mothers� concerns about the side effects of drugs for themselves or for their nursing baby, they seek alternative and complementary methods for treating their symptoms. Therefore, the use of alternative medicine is better for patients (15). Alternative therapies for the treatment of various physical and mental distresses are available for young women (16). One of the treatment methods, which has expanded in recent years is aromatherapy. This treatment is the second alternative treatment method, which uses essential oil extracted from aromatic plants for the treatment. Lavender ( Lavandula angustifolia), which belongs to green mint family and aromatic plants is one of the most used aromatic plants in aromatherapy (15). Several studies have been conducted on the effects of aromatherapy in sleep-related disorders. For example, in a study conducted by Chien et al. the overall score of quality of sleep has been improved in the group who did inhale lavender aroma (17). According to the research conducted by Lee et al. who studied the effects of Lavender oil aromatherapy on insomnia in Korean female students, it was found that this treatment significantly reduces insomnia (18). Also, the research of Moeini et al. showed that lavender aromatherapy improved sleep quality in patients in CCU (15). In another study, Arzi et al. showed that the scent of lavender only improved the repeated wakening and had no other effects (19). However, there have been a few clinical trials that studied the improvement of mothers� sleep quality during postpartum period. For example, in a study conducted by Lee et al. with the purpose of investigating the effects of aro matherapy on sleep quality and fatigue in postpartum mothers, the results showed that inhaled aromatherapy has no significant effects on sleep quality with regard to sleep duration, the numbers of waking up at nights, and sleep satisfaction (11). Given the importance of sleep quality in postpartum period, its adverse effects on the quality of life and ability of midwives to prescribe and use complementary medicine and considering the lack of studies in Iran on the effectiveness of aromatherapy (on sleep quality in this period of life), we decided to assess the effects of aromatherapy on sleep quality in postpartum period. 2. Objectives This study aimed to determine the effect of aromatherapy on the quality of sleep in postpartum women. The sample was recruited from medical health centers of Zanjan University of Medical Sciences. This study was carried out with the hypothesis that the mean score of quality of sleep would be better in postpartum women in aromatherapy group compared to control group. 3. Patients and Methods This study was a randomized clinical trial with a control group, in which the data were collected from both groups before and after the intervention. The study population consisted of all women who have recently given birth and covered by health-care referral governmental centers affiliated to Zanjan University of Medical Sciences. This study was registered in Iranian Registry of Clinical Trials (registration number of IRCT201211179463N8) and approved by the Ethics Committee of Tehran University of Medical Sciences (No. 130/904/D/92). The sampling began in December 19, 2013 and lasted for 6 months. The sample size was calculated according to the previous articles (15, 20) and by the advice of the statistics professor using OpenEpi (www.OpenEpi. com) software (21). The number of individuals in each group was calculated as 61. Because of the availability of samples and willingness of individuals to participate in the study, 79 subjects were enrolled in each group. Out of 4 health centers in Zanjan that conducted hypothyroidism and phenylketonuria screening tests, 2 of them have been chosen randomly and sampling of intervention and control groups began at those centers. The reason for choosing centers that provide neonatal screening for sampling was the attendance of the mothers in first few days after delivery as well as future referrals for postpartum care, which provided an easy access to samples for the research. Participants satisfied inclusion criteria were enrolled after completing an informed consent form. Inclusion criteria included primiparous women, uncomplicated vaginal delivery, a minimum literacy tips, aged 18 - 35 years, absence of acute or chronic physical and mental illness, being exclusive breast-feeders of their infants, having healthy Iran Red Crescent Med J. 2015;17(4):e25880 Keshavarz Afshar M et al. baby without complications, and sleep disorders (The Pittsburgh Sleep Quality Index score of 5 or higher). Exclusion criteria were having chronic diseases (diabetes), using certain drugs such as hypnotics or sedatives, having a history of allergy to herbal remedies, and suffering from depression. Randomization was performed by simple allocation. Sampling continued until 79 patients were allocated in each group. Then, the researcher followed the participants with phone calls and text messages and reminded them about the intervention so that nobody dropped out of the study. The aromatherapy blend used in this study consisted of 10% lavender essential oil of sesame carrier oil and placebo was just sesame carrier oil, which was produced by Barij Essence Pharmaceutical Co. in Iran under Batch No 9208051. The intervention consisted of inhaling the aroma of lavender essential oil, by the intervention group used at night and before sleeping. They dropped 4 drops of essential oil on a cotton ball, placed on a cylindrical container at their disposal and with a projected distance of 20 cm. They inhaled 10 deep breaths and then placed the container beside their pillow until morning. The control group was also treated in the same manner except that a placebo was inhaled by the participants. All participants were asked to inhale the lavender essential oil during bed time until the next morning and preferably for 4 consecutive days per week for 8 weeks. To ensure its proper execution, a check list was provided for the participants, and each week, the researcher reminded the participants of the intervention with a phone call or short text message. Furthermore, the contact number of the researcher was provided for the participants. If for any reason, subjects did not complete the aromatherapy for 4 times a week, they would be excluded from the study. In this study, the tools that have been used by the researcher for demographic data collection comprised a questionnaire survey of environmental confounding factors affecting sleep, Pittsburgh sleep quality index, and the Edinburgh Postnatal Depression Scale as well as aromatherapy and registration forms that were completed by mothers. Pittsburgh sleep quality index is an international standardized tool that has been validated in numerous studies (15, 20). Test-retest reliability and content validity of its Iranian version have been reviewed and approved in two studies done by Hossein Abadi et al. (4) and Malekzadegan et al. (22) whose results showed the specificity of 87% with a sensitivity of 90%. Test-retest reliability has been determined in the study of Malekzadegan et al. (22) and Cronbach a was evaluated at 88% in the study of Hossein Abadi et al. (4, 20, 22, 23). Pittsburgh Sleep Quality Index consisted of 19 questions that evaluate the quality of sleep in the past month and measures 7 dimensions (24). The total score of this index ranges from 0 to 21, which a total score of 5 or more denotes poor sleep quality and shows that the individual has some problems in 2 or more dimensions (24). This scale was completed by the researcher in the meetings with the mothers at the health centers 3 - 5 days after birth, then at the end of the first four weeks and finally at the end of the second four weeks after labor. Because of the poor quality of sleep in cases of postpartum depression in mothers (10), and its effect as a confounding factor, Edinburgh Postnatal Depression Scale has been performed by the researcher in health centers at the beginning of the study and before the intervention. In case of scoring 10 or higher, the samples were excluded from the study with a diagnosis of postpartum depression. Edinburgh Postnatal Depression Scale is a universal standardized tool that its reliability and validity have been confirmed by Boyed and colleagues (20). Confounding factors have been also examined by a researcher form that has been performed before the intervention. 3.1. Statistical Analysis Descriptive statistics, including means and standard deviations were calculated for all variables. Independent t test, Chi-square, and repeated measure test were used to compare means of the impact of lavandula aromatherapy and placebo on the sleep quality between two groups (case and control). The data were analyzed using version 16 of SPSS software. The characteristics of the participants are presented as mean (SD), or number (percentage). Differences between variables were determined by independent t test and repeated measure test. P value < 0.05 was considered as significant (Figure 1). 4. Results Demographic characteristics of study subjects and their husbands are shown in Table 1. Mothers in both groups were similar in all demographic characteristics (P > 0.05). In terms of individual-environmental confounding factors affecting sleep disorders such as lighting a bedroom, existence of noise, consuming tea and coffee, consuming caffeinated soft drinks, herbal remedies, complaining of pain, general sleep conditions of infants, and assistance in infants care in two groups showed no significant differences (P > 0.05). Table 2 shows the mean and standard deviation of sleep quality index at the beginning of the study, at the end of the four weeks, and eight weeks after intervention in two groups. As a result, the mean score of sleep quality at baseline in aromatherapy was (8.28 � 2.11) and in placebo group was (8.45 � 2.30) and before the intervention there was no significant difference between the two groups in mean score of quality of sleep (P > 0.05). Four weeks after the intervention, the result showed the mean of quality of sleep in aromatherapy group was (7.59 � 2.53) and placebo group was (8.06 � 2.20), and finally, the average of the quality of sleep after eight weeks in the intervention group was (6.79 � 2.36) and in the placebo group was (7.56 � 2.14). Analysis of the data revealed that despite the improvements in sleep quality after 4 weeks of intervention, Iran Red Crescent Med J. 2015;17(4):e25880 Keshavarz Afshar M et al. One hundred and fifty-eight postpartum women with sleep score 5 or over were randomly devided in to two groups. group B (n = 79) case group group A (n = 79) control group inhaling lavender essential oil inhaling placebo 79 persons included in two follow-up in 8 weeks 79 persons included in two follow-up in 8 weeks Analysis with SPSS 16 Figure 1. Study Method Design Table 1. Demographic Data of Women and Their Husbands Participating in the Study a Variables Group Case Control Independent t test and Chi-square Test Women�s mean age, y 28.06 � 4.105 28.14 � 4.128 P Value = 0.908 Husbands� mean age, y 31.75 � 5.06 32.12 � 5.05 P Value = 0.649 Women�s degree of education P Value = 0.726 Primary School 3 (3.8) 2 (2.5) High school 3 (3.8) 6 (7.6) Diploma 24 (30.4) 25 (31.6) University 49 (62) 46 (58.2) Husbands� degree of education P Value = 0.854 Primary school 3 (3.8) 2 (2.5) High school 6 (7.6) 6 (7.6) Diploma 49 (52) 44 (55.7) University 21 (26.6) 27 (34.2) Womens� job P Value = 0.869 Housewife 58 (73.2) 59 (72.7) Employee 12 (15.3) 14 (17.7) Student 6 (7.7) 5 (6.3) Self-employed 3 (3.8) 1 (1.3) Husbands� job P Value = 0.352 Employee 28 (35.4) 23 (29.1) Worker 15 (19) 10 (12.7) Self-employed 33 (41.8) 41 (51.9) other 3 (3.8) 5 (6.3) The income from the perspective of women P Value = 0.897 Sufficient 27 (34.2) 28 (35.4) Nearly Sufficient 49 (62) 49 (62) Insufficient 3 (3.8) 2 (2.5) a Data are presented as No. (%) or Mean � SD. 4 Iran Red Crescent Med J. 2015;17(4):e25880 Keshavarz Afshar M et al. Table 2. Comparison of the Quality of Sleep in Postpartum Women Between Case and Control Groups Before and After the Intervention Variable Intervention Mean � SD P Value a Before intervention 0.64 Case 8.2911 � 2.11922 Control 8.4557 � 2.30272 4 weeks after intervention 0.216 Case 7.5949 � 2.52941 Control 8.0633 � 2.20339 8 weeks after intervention 0.033 Case 6.7975 � 2.36632 Control 7.5696 � 1.14646 a Independent t test. Table 3. Comparison of the Quality of Sleep Between Postpartum Women in Control and Case Groups After the Intervention a , b Variable Before Intervention 4 Weeks After Intervention 8 Weeks After Intervention P Value c Quality of Sleep 0.002 Case 8.2911 � 2.1192 7.5949 � 2.5294 6.7975 � 2.3663 Control 8.4557 � 2.3027 8.0633 � 2.2033 7.5696 � 1.1464 a Data are presented as Mean � SD. b Repeated measure test. c P value < 0.05 were considered as significant. Estimated Marginal Means of PSQI Estimated Marginal Means of PSQI time 8.50 group .00 8.50 1.00 4.00 8.00 2.00 Estimated Marginal Means Estimated Marginal Means 8.00 7.50 7.00 6.50 Figure 2. Estimated Marginal Mean of Pittsburgh Sleep Quality Index Figure 3. Estimated Marginal Mean of Pittsburgh Sleep Quality Index .00 4.00 8.00 time 1.00 2.00 group there were no significant differences between the intervention and control groups (P > 0.05). However, eight weeks after intervention, a significant difference was observed between two groups (P < 0.05). To examine differences in sleep quality means between mothers in both groups over time, repeated measures tests have been performed. Before performing this analysis, assumptions, including homogeneity of variances and normal response variables were examined, which confirmed the establishment of the assumptions. By considering time and intervention concurrency at the end of eight weeks compared to the pre-intervention condition, aromatherapy significantly increased sleep quality from (8.28 � 2.11) to (6.79 � 2.36) (P . 0.05). While at the end of eight weeks (compared to the pre-intervention conditions), no significant change was observed in placebo group in comparison to aroma group: 8.45 � 2.30 to 7.56 � 2.14 (P .0.05) (Table 3, Figures 2 and 3). Iran Red Crescent Med J. 2015;17(4):e25880 Keshavarz Afshar M et al. 5. Discussion The present study was conducted with the purpose of investigating the effects of aromatherapy on sleep quality of the women during their postpartum period. Comparing two groups of intervention and control showed the effectiveness of aromatherapy on mothers� sleep quality. Inhaling this aroma affected some aspects of sleep quality, including sleep latency and duration, while it had no statistically significant impact on other aspects (P < 0.05). These findings are consistent with the results of Chien et al. (17) study about the effects of lavender essential oil on autonomic nervous system of middle-aged women suffering from insomnia. The total score of sleep quality after aromatherapy with lavender essential oil reduced after the intervention, but there was no change in sleep quality score in the control group. The results from a study conducted by Hirokawa et al. (23) showed that lavender essential oil improves sleepiness during wakefulness. Also in a study conducted by Moeini et al. (15) the total score of sleep quality in those who did inhale lavender essential oil decreased while in the control group there was no change in sleep quality score after the same period of time. Another study by Field and colleagues (2008) with the purpose of studying the effects of aromatherapy in reducing infants� stress and crying as well as enhancing their sleep showed the improvement of sleep quality after aromatherapy with lavender oil (25). Based on a study done by Lee about the effects of aromatherapy on the quality of sleep and fatigue level of the mothers in the postpartum period, inhaled aromatherapy had no effect on the duration of sleep, frequency of night waking, and sleep satisfaction (11). These different results might be due to the following reasons: 1) mothers in this study were enrolled with adequate sleep quality. 2) duration of aromatherapy was short 3) questionnaire used in the study was a self-designed questionnaire; moreover 4) PSQL, RCSQ and HCAMQ standardized questionnaire that has been used in the previous studies, were not used in this particular study. Today, aromatherapy has been considered as an alternative medicine approach with a positive impact and tested in various researches however, the mechanism of its effects on sleep quality and its patterns are poorly understood. Nevertheless, in principle the sense of smell plays an important role in overall health as well as physical and mental relaxation and the brain responds emotionally to aroma (24). In the postpartum period, because of the conditions and problems such as pain, sudden hormonal changes in mothers and taking care of the baby, using aromatherapy seems to be beneficial as a convenient and easily accessible method for improving sleep quality of mothers, which results in the infant and family health too. Despite several studies in the field of aromatherapy on sleep quality in different periods of life and under different health conditions, a few studies have investigated the effects of aromatherapy on the sleep quality in women during the critical postpartum period to generalize the results. Therefore, this field of investigation requires more research. The strong points of this paper are the careful and continuous follow-up in addition to use of complementary medicine that has no known compilations. The weak point of this study relates to the factors that affect the quality of sleep and were out of our control. This study is a clinical trial that examined the effects of aromatherapy on sleep quality in women during postpartum period. Lavender aromatherapy improves the quality of sleep in postpartum women. Acknowledgements We would like to thank the participants in this research, all people in charge in Tehran University of Medical Sciences, Zanjan University of Medical Sciences and Barij Essence Company, for their assistance and cooperation. Funding/Support This study was financially supported by Tehran University of Medical Sciences. Authors� Contributions Mahnaz Keshavarz Afshar: Data collection, as well as design and writing the manuscript, Zahra Behboodi Moghadam: Supervisor, design and writing the manuscript, Pouran Mokhtari and Ziba Taghizadeh: Counselor, Ali Montazeri: Data analysis, Reza Bekhradi: Material providing. Financial Disclosure This project has been approved and financially supported by Tehran University of Medical Sciences. The interventional drug and placebo was manufactured by the support of Barij Essence Company. References 1. Li CY, Chen SC, Li CY, Gau ML, Huang CM. 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Evid Based Complement Alternat Med. 2012;2012:740813. 18. Lee IS, Lee GJ. [Effects of lavender aromatherapy on insomnia and depression in women college students]. Taehan Kanho Hakhoe Chi. 2006;36(1):136�43. 19. Arzi A, Sela L, Green A, Givaty G, Dagan Y, Sobel N. The influence of odorants on respiratory patterns in sleep. Chem Senses. 2010;35(1):31�40. 20. Jahdi F, Behboodi Moghadam Z, Hagani H. The impact of Health Behavior Education on the Sleep Quality in the Pregnant Women with sleep disorder: A Randomized Control Trial 2011-2012. Int Res J Applied Basic Sci. 2013;7(12):921�8. 21. Sullivan KM, Dean A, Soe MM. OpenEpi: a web-based epidemiologic and statistical calculator for public health. Public Health Rep. 2009;124(3):471�4. 22. Malekzadegan A, Moradkhani M, Ashaeri H, Haghani H. The effects of Relaxation exercise training on the sleep disorders in the third trimester of pregnancy, pregnant women referred to health centers in Zanjan. Sch Nurs Midwifery Iran Univ Med Sci Iran. 2005;1385. 23. Hirokawa K, Nishimoto T, Taniguchi T. Effects of lavender aroma on sleep quality in healthy Japanese students. Percept Mot Skills. 2012;114(1):111�22. 24. Pillitteri A. Maternal & child health nursing: care of the childbearing and childrearing famil.: Lippincott Williams and Wilkins; 2010. 25. Field T, Field T, Cullen C, Largie S, Diego M, Schanberg S, et al. Lavender bath oil reduces stress and crying and enhances sleep in very young infants. Early Hum Dev. 2008;84(6):399�401. Iran Red Crescent Med J. 2015;17(4):e25880 PENURUNAN INTENSITAS NYERI AKIBAT LUKA POST SECTIO CAESAREA SETELAH DILAKUKAN LATIHAN TEKNIK RELAKSASI PERNAPASAN MENGGUNAKAN AROMATERAPI LAVENDER DI RUMAH SAKIT AL ISLAM BANDUNG Ratna Pratiwi1Ermiati1Restuning Widiasih1 1Fakultas Ilmu Keperawatan Universitas Padjadjaran, Bandung, Jawa Barat ABSTRAK Persalinan dengan sectio caesarea dapat menimbulkan dampak setelah operasi yaitu nyeri. Adapun teknik penurunan nyeri yang dapat dilakukan yaitu dengan latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender. Penelitian ini bertujuan untuk mengetahui pengaruh latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender. Sampel penelitian ini berjumlah 30 ibu post sectio caesarea hari pertama yang diambil dengan teknik purposive sampling. Pengambilan data dilakukan di ruang nifas Rumah Sakit Al Islam, dengan menggunakan lembar observasi menggunakan skala VAS pada bulan Mei � Juni 2012. Analisa data menggunakan uji Wilcoxon. Hasil penelitian menunjukkan intensitas skala nyeri sebelum dilakukan intervensi adalah 6.6 dimana nilai tersebut masuk dalam kategori nyeri berat tertahankan. Sedangkan sesudah dilakukan adalah 3.6 dimana nilai tersebut masuk dalam kategori sedang. Hasil analisis lebih lanjut didapatkan bahwa p= 0.000 dengan taraf signifikan < 0.05, yang berarti ada perbedaan yang signifikan dari intensitas nyeri sebelum dan setelah dilakukan latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender. Kata Kunci : Sectio Caesarea, Nyeri, Relaksasi Pernapasan, Aromaterapi ABSTRACT Parturition by sectio Caesarea may cause effects including pain after surgery. The pain reduction techniques that can be done is to practice relaxation breathing techniques using lavender aromatherapy. The aim this research is to determine the effect of breathing exercises relaxation techniques using lavender aromatherapy. The sample consists of 30 mother post sectio caesarea first day taken by purposive sampling technique. Data is collected in the puerperal Hospital Al Islam, using the observation sheet and VAS scale at May � June 2012. Data analysis using Wilcoxon test. The results showed the average pain scale before intervention 6.63 where the value is in the category of controlled severe pain. Whereas after the relaxation breathing techniques exercise using lavender aromatherapy is 3.6 where the value is in the category of moderate. The analysis further found that p=0000 with <0.05 significant level, which means there is a significant difference of pain intensity before and after breathing relaxation techniques exercise using lavender aromatherapy. Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] Key words : Sectio Caesarea, Pain, Breathing Relaxation, Aromatheray PENDAHULUAN Persalinan normal merupakan proses dari mulai mulesnya ibu sampai pada keluarnya bayi dengan kondisi kepala dahulu melalui vagina, dengan lama persalinan kurang dari 24 jam (Whalley, 2008). Proses ini kadang tidak berjalan semestinya dan janin tidak dapat lahir secara normal karena beberapa faktor, yaitu komplikasi kehamilan, disproporsi sefalo-pelvik, partus lama, ruptur uteri, cairan ketuban yang tidak normal, kepala panggul. Keadaan tersebut perlu tindakan medis berupa operasi sectio caesarea (Padilla, et al.,2008). Sectio caesarea adalah melahirkan janin melalui insisi pada dinding abdomen (laparotomi) dan dinding uterus (histerotomi) (Cunningham, 2006). Persalinan secara sectio caesarea dapat memungkinkan terjadinya komplikasi lebih tinggi dari pada melahirkan secara pervagina atau persalinan normal. Komplikasi yang bisa timbul pada ibu post sectio caesarea seperti nyeri pada daerah insisi, potensi terjadinya thrombosis, potensi terjadinya penurunan kemampuan fungsional, penurunan elastisitas otot perut dan otot dasar panggul, perdarahan, luka kandung kemih, infeksi, bengkak pada ektremitas bawah dan gangguan laktasi (Rustam M, 1998). Hal tersebut dapat diatasi secara langsung oleh tim medis agar ibu cepat sembuh dan lama rawat inap lebih cepat. Tindakan operasi sectio caesarea menyebabkan nyeri dan mengakibatkan terjadinya perubahan kontinuitas jaringan karena adanya pembedahan. Pada proses operasi digunakan anestesi agar pasien tidak nyeri pada saat dibedah. Namun setelah operasi selesai dan pasien mulai sadar, akan merasakan nyeri di daerah sayatan yang membuat sangat terganggu (Whalley, dkk 2008). Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] Nyeri tersebut akan menimbulkan berbagai masalah, salah satunya masalah laktasi. Menurut Hillan (1992) dalam Anggorowati, dkk 2007 bahwa 68% ibu post sectio caesarea mengalami kesulitan dengan perawatan bayi, bergerak naik turun dari tempat tidur dan mengatur posisi yang nyaman selama menyusui akibat adanya nyeri. Rasa nyeri tersebut akan menyebabkan pasien menunda pemberian ASI sejak awal pada bayinya, karena rasa tidak nyaman selama proses menyusui berlangsung atau peningkatan intensitas nyeri setelah operasi (Batubara dkk, 2008). Adapun dampaknya terhadap bayi adalah dalam pemberian ASI dan kurangnya perawatan bayi yang dilakukan oleh ibunya. Pemberian nutrisi untuk bayi berkurang karena tertundanya pemberian ASI sejak awal, respiratorik terganggu dan daya tahan imun rendah (Indiarti, 2009). Respon ibu dalam memberikan ASI kurang, maka ASI sebagai makan terbaik bagi bayi dan mempunyai banyak manfaat bagi bayi maupun ibunya tidak dapat secara optimal. Penanganan yang sering digunakan untuk menurunkan nyeri post sectio caesarea berupa penanganan farmakologi, biasanya untuk menghilangkan nyeri digunakan analgesik yang terbagi menjadi dua golongan yaitu analgesik non narkotik dan analgesik narkotik. Pengendalian nyeri secara farmakologi efektif untuk nyeri sedang dan berat. Namun demikian pemberian farmakologi tidak bertujuan untuk meningkatkan kemampuan klien sendiri untuk mengontrol nyerinya (Van Kooten, 1999 dalam Anggorowati dkk., 2007). Sehingga dibutuhkan kombinasi farmakologi untuk mengontrol nyeri dengan non farmakologi agar sensasi nyeri Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] dapat berkurang serta masa pemulihan tidak memanjang (Bobak, 2004). Metode non farmakologi tersebut bukan merupakan pengganti untuk obat-obatan, tindakan tersebut diperlukan untuk mempersingkat episode nyeri yang berlangsung hanya beberapa detik atau menit. Dalam hal ini, terutama saat nyeri hebat yang berlangsung selama berjam-jam atau berhari-hari, mengkombinasikan metode non farmakologi dengan obat-obatan mungkin cara yang paling efektif untuk mengontrol nyeri. Pengendalian nyeri non-farmakologi menjadi lebih murah, simpel, efektif dan tanpa efek yang merugikan (Potter, 2005). Menurut hasil penelitian tentang teknik relaksasi nafas dalam terhadap penurunan tingkat nyeri pada pasien pasca operasi fraktur femur di Rumah Sakit Karima Utama Surakarta tahun 2009 oleh Ayudianningsih menyebutkan bahwa ada pengaruh yang signifikan teknik relaksasi nafas dalam terhadap penurunan nyeri pada pasien pasca operasi fraktur femur antara kelompok eksperimen dan kelompok kontrol di Rumah Sakit Karima Utama Surakarta. Adapun menurut Saekhatun (2008) mengatakan bahwa ada hubungannya sikap perawat dengan tindakan perawat dalam manajemen nyeri dengan teknik distraksi pada pasien post operasi. Ketika seseorang melakukan relaksasi pernapasan untuk mengendalikan nyeri, di dalam tubuh tersebut meningkatkan komponen saraf parasimpatik secara stimulan maka hormon adrenalin dan kortisol yang dapat menyebabkan stres akan menurun sehingga meningkatkan konsentrasi serta merasa tenang untuk mengatur napas sampai pernapasan kurang dari 60 � 70 x/menit. Kemudian kadar PaCO2 akan meningkat dan menurunkan pH sehingga akan meningkatkan kadar oksigen Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] dalam darah (Handerson, 2005). Teori relaksasi pernapasan ini menjelaskan bahwa pada spinal cord, sel-sel reseptor yang menerima stimulasi nyeri periferal dihambat oleh stimulasi dari serabut-serabut saraf yang lain. Stimulasi yang menyenangkan dari luar juga dapat merangsang sekresi endorfin, sehingga stimulasi nyeri yang dirasakan oleh klien menjadi berkurang (Priharjo, 2003). Periode relaksasi pernapasan yang teratur dapat membantu untuk melawan keletihan, ketegangan otot yang terjadi akibat meningkatkan nyeri (Smeltzer dan Bare, 2002). Pengaruh aromaterapi terhadap kenyamanan dapat diukur dengan melihat berbagai indikator yang memperlihatkan kenyamanan. Indikator tersebut adalah interpretasi terhadap aromaterapi itu sendiri akan menunjukan respon emosi fight or flight, interpretasi terhadap rasa nyaman yang di dapat dari efek aromaterapi, pernyataan bahwa aromaterapi meningkatkan kinerja, peningkatan konsentrasi, pikiran lebih tenang, jiwa menjadi sejuk (Price, 1997). Respon non verbal menunjukan kenyamanan (tidak ada kerut muka, tidak ada gerakan menjauhkan diri, tidak ada pengatupan kelopak mata, tidak ada pemalingan wajah/seluruh badan) (Atkinson, R 1999). Menurut Hutasoit (2002), bahwa lavender mempunyai efek menenangkan. Lavender memberikan ketenangan, keseimbangan, rasa nyaman, rasa keterbukaan dan keyakinan. Selain itu lavender dapat mengurangi rasa tertekan, stress, rasa sakit, emosi yang tidak seimbang, histeria, rasa frustasi dan kepanikan. Lavender bermanfaat mengurangi rasa nyeri, dan dapat memberikan relaksasi (Woodcock, 2008 dalam Sulistyowati, 2009). Penelitian Hale (2008), bahwa wanita yang Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] menjalani persalinan menggunakan minyak lavender dapat mengurangi rasa nyeri pada daerah perineum dan mengurangi kegelisahan. METODE PENELITIAN Jenis penelitian yang digunakan adalah Quasi Eksperimen dengan rancangan penelitian One Group Pre-test Post-test yaitu sampel pada penelitian ini diobservasi terlebih dahulu sebelum diberi perlakuan, kemudian diobservasi kembali setelah diberi perlakuan (Notoatmodjo, 2010). Populasi pada penelitian ini adalah ibu post sectio caesarea di ruang nifas Rumah Sakit Al Islam. Hasil data dari laporan kegiatan instalasi obgin Rumah Sakit Al Islam jumlah ibu yang melakukan persalinan sectio caesarea pada 3 bulan terakhir periode Oktober � Desember 2011 berjumlah 127 orang (medical record Rumah Sakit Al Islam, 2011). Pengambilan sampel dalam penelitian ini adalah dengan menggunakan teknik purposive sampling. Dengan kriteria inklusi Pasien post sectio caesarea yang menggunakan anastesi umum, belum mendapatkan latihan teknik relaksasi pernapasan, pasien yang tidak alergi dengan aromaterapi. Teknik pengumpulan data dalam penelitian ini dengan lembar observasi VAS. Peneliti bekerja sama dengan kolektor data yang bertugas di ruang nifas Rumah Sakit Al Islam. Tetapi sebelumnya, peneliti menyamakan persepsi dengan memberi pengarahan kepada kolektor data yaitu perawat dengan menjelaskan tujuan dari penelitian. Penelitian mengkategorikan intensitas nyeri sebelum dilakukan teknik relaksasi pernapasan dan intensitas nyeri sesudah dilakukan teknik relaksasi pernapasan. Skala pengukuran data yang digunakan untuk meneliti pengaruh Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] latihan teknik relaksasi pernapasan terhadap nyeri akibat post sectio caesarea dalam penelitian ini adalah skala ordinal. Pengumpulan data ini dilakukan pada ibu post sectio caesarea di ruang nifas Rumah Sakit Al Islam Bandung. Pelaksanaan dan pengumpulan data dilakukan oleh peneliti dan dibantu oleh kolektor data seorang perawat. Pengumpulan data dilaksanakan pada tanggal 14 Mei � 7 Juni 2012. HASIL DAN PEMBAHASAN Deskripsi hasil penelitian ditampilkan dalam tabel berikut: Tabel 1 Distribusi Frekuensi Karakteristik Paritas Ibu Post Sectio Caesarea di Rumah Sakit Al Islam Bandung (n=30) Karakteristik Frekuensi Presentase Paritas Primipara 11 36.67 Multipara 19 63.33 Riwayat Persalinan Pertama Sectio Caesarea 19 63.33 Pernah Sectio Caesarea 11 36.67 Rentang Usia <20 Tahun 2 6.67 20 � 35 Tahun 23 76.67 >35 Tahun 5 16.67 Pendidikan Dasar (SD, SMP) 3 10.00 Menengah (SMA) 7 23.33 Perguruan Tinggi 20 66.67 Pekerjaan IRT 17 56.67 PNS 7 23.33 Karyawan 6 20.00 Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] Tabel 2 Frekuensi Intensitas Nyeri Sebelum dan Sesudah Dilakukan Latihan Teknik Relaksasi Pernapasan Menggunakan Aromaterapi Lavander (n=30) Kategori Sebelum Sesudah Skala Nyeri Frekuensi Persentase Frekuensi Persentase Tidak nyeri 0 0 0 0 Nyeri ringan 0 0 13 43.33 Nyeri sedang 13 43.33 17 56.67 Nyeri berat 17 56.67 0 0 terkontrol Nyeri berat tidak 0 0 0 0 terkontrol Tabel 3 Tingkat Nyeri Sebelum dan Sesudah dilakukan Latihan Teknik Relaksasi Pernapasan Menggunakan Aromaterapi Lavander (n=30) Kelompok Mean SD Min Maks P Value Pre test 6.6 0.81 5 8 0.000 Post test 3.6 0.72 3 5 Penurunan intensitas nyeri pada responden ini terjadi karena ibu post sectio caesarea dapat mempraktekkan latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender dengan benar dan lama waktu latihan kurang lebih 15 menit, dilakukan pada saat ibu merasakan nyeri pada luka bekas sectio caesarea. Menurut Indiarti (2009) menggunakan relaksasi dengan induksi latihan relaksasi pernapasan selama 15 -20 menit secara teratur dapat mengurangi rasa nyeri. Latihan teknik relaksasi pernapasan dengan aromaterapi lavender dapat dilakukan sebelum keluhan nyeri terasa. Ibu post sectio caesarea dapat mempraktekkan latihan pernapasannya untuk mengatasi rasa nyeri pada saat memiringkan badan dan mengatur posisi. Latihan teknik relaksasi pernapasan bisa berhasil jika pasien kooperatif (Potter dan Perry, 2006). Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] Hasil penelitian ini hampir sama dengan hasil penelitian yang telah dilakukan oleh Priyani (2009) yang menyatakan bahwa ada pengaruh yang signifikan antara pemberian teknik relaksasi napas dalam terhadap penurunan nyeri dismenore pada remaja putri di Panti Asuhan Yatim Putri Islam Yogyakarta dengan nilai signifikansi (p) = 0.000. Nyeri merupakan perasaan emosional yang bersifat subjektif dan hanya seseorang dengan kondisi tersebut yang dapat mendeskripsikan besarnya nyeri yang dirasakan. Sehingga akan berpengaruh terhadap penurunan skala intensitas nyeri pada tiap responden. Nyeri sendiri muncul karena adanya kiriman impuls yang memasuki medulla spinalis dan berinteraksi dengan sel � sel saraf inhibitor, sehingga akan ditransmisi mencapai ke korteks serebral untuk diinterpretasikan sensasi nyeri (Potter dan Perry, 2005). Reaksi lokal adanya nyeri itu juga mengaktifkan syaraf � syaraf simpatif, berupa keluarnya keringat yang berlebihan, respon metabolisme yang meningkat, meningkatan kardiovaskuler. Nyeri tersebut menimbulkan perasaan sensori dan emosional yang tidak menyenangkan akibat dari kerusakan jaringan. Tingkat dan keparahan nyeri pasca operasi terganggu pada fisiologis dan psikologis individu dan toleransi yang ditimbulkkan (Brunner dan Suddart, 2002). Pengontrolan nyeri setelah post sectio caesarea sangatlah penting untuk mengurangi kecemasan dan mempercepat mobilisasi serta rawat inap. Nyeri yang dirasakan ibu post sectio caesarea dapat dikendalikan dengan metode penatalaksanaan nyeri seperti yang dilakukan peneliti terhadap penelitiannya. Metode penatalaksanaan nyeri tersebut dapat dikelompokkan menjadi metode farmakologi dan metode non farmakologi. Penelitian yang sudah Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] dilakukan Kim pada tahun 2007 menyebutkan bahwa penggunaan terapi aroma untuk perawatan post operasi anastesi dengan pemakaian aromaterapi lavender memiliki pengaruh yang signifikan dan lebih efektif dibandingkan dengan pemakaian sedatif. Selain itu, hasil yang diperoleh mengenai kegiatan penelitian ini yaitu pemakaian terapi aroma lavender lebih efektif dalam proses penurunan nyeri dibandingkan dengan pemakaian analgesik (P= 0.007). Kedua jenis metode tersebut dapat dikombinasikan satu sama lain sehingga lebih cepat dalam proses penurunan tingkat intensitas nyeri. Namun demikian, metode non farmakologi memiliki kelebihan yaitu proses pelaksanaannya relatif sederhana, efektif, dan tidak menimbulkan efek yang merugikan (Perry dan Potter, 2005). Relaksasi merupakan salah satu metode pengendalian nyeri yang sering digunakan dan memberikan masukan terbesar dalam penurunan nyeri. Hal ini sesuai dengan penelitian yang dilakukan oleh Bagharpoosh dkk (2006) dalam Sulistyowati (2009) menunjukkan bahwa relaksasi sangat efektif untuk mengurangi nyeri, merupakan cara mudah yang dapat dilakukan, tanpa resiko dan hanya memerlukan sedikit biaya. Terapi aroma merupakan tindakan terapeutik dengan menggunakan minyak esensial yang bermanfaat untuk meningkatkan keadaan fisik dan psikologi. Latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender ini dimulai pada saat responden yaitu ibu post sectio caesarea menarik napas, respon aroma yang dihasilkan aromaterapi lavender akan merangsang kerja sel otak. Aromaterapi tersebut memiliki efek positif karena aroma atau baunya yang segar dan harum mampu merangsang sensori dan reseptor sehingga dapat Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] mempengaruhi organ tubuh dan menimbulkan efek kuat terhadap emosi (Shinobi, 2008). Prinsip dasar teori penurunan nyeri oleh teknik relaksasi pernapasan menggunakan aromaterapi lavender adalah teori gate control yang terletak pada fisiologis sistem saraf otonom yang merupakan bagian dari sistem yang mempertahankan homeostatis. Menurut Melzack dan Wall (1965) teori gate control menjelaskan mekanisme pertahanan dan impul di saraf pusat. Latihan teknik relaksasi pernapasan dengan aromaterapi lavender mempengaruhi pelancaran sirkulasi darah, sehingga suplai nutrisi ke jaringan luka dapat tercukupi dan proses penyembuhan akan lebih cepat. Teknik napas dalam juga dapat memberikan individu kontrol diri ketika terjadi rasa ketidaknyamanan atau cemas, stres fisik dan emosi yang menyebabkan nyeri meningkat. Penelitian yang dilakukan Sulistyowati (2009) menyebutkan bahwa penggunaan terapi aroma lavender dapat efektif digunakaan untuk mengatasi nyeri dan cemas pada saat persalinan kala 1 dengan hasil selisih pre post test nyeri dan cemas persalinan antara kelompok kontrol dan eksperimen berbeda signifikan (p > 0.005) (p < 0.005). Pernyataan tersebut juga diperkuat oleh Hutasoit (2002) yang menyebutkan bahwa lavender mempunyai aefek menenangkan sehingga dapat memberikan ketenangan, keseimbangan, dan rasa nyaman. Di samping itu terapi aroma lavender juga dapat mengurangi rasa tertekan, stres, rasa sakit, emosi yang tidak seimbang, histeria, serta rasa frustasi dan kepanikan. Dalam penelitian ini cara yang digunakan adalah dengan menyegarkan ruangan atau vapourizer dengan menggunakan tungku pemanas. Cara tersebut sangat sederhana dengan hanya Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] meletakkan sedikit air dan aromaterapi di atas alat pemanas yang dibakar oleh lilin aroma sehingga menimbulkan wewangian. Berdasarkan pembahasan mengenai hasil penelitian dari peneliti dan peneliti-peneliti sebelumnya, tentu saja diperlukan adanya solusi dari permasalahan yang berkaitan dengan tingkat intensitas nyeri pada ibu post sectio caesarea. Oleh karena itu, untuk mengatasi masalah ini tentu saja diperlukan adanya peningkatan dari penggabungan metode farmakologi dan non farmakologi secara efektif dan menyeluruh. Metode non farmakologi berupa latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender diharapkan dapat menjadi komplementer bagi ibu post sectio caesarea untuk dapat mengontrol nyeri yang dirasakan secara tiba-tiba sehingga nantinya aktivitas ibu post sectio caesarea tidak terganggu serta dapat melewati fase latting go (kemandirian) sesegera mungkin. SIMPULAN Berdasarkan hasil penelitian yang dilakukan terhadap 30 ibu post sectio caesarea di ruang nifas Rumah Sakit Al Islam Bandung dapat disimpulkan sebelum diberikan latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender, intensitas skala nyeri sangat tinggi dimana nilai tersebut masuk dalam kategori berat tertahankan, adapun sesudah diberikan latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender intensitas skala nyeri pada responden berubah tersebut masuk dalam kategori sedang. Terdapat perbedaan yang signifikan antara intensitas skala nyeri sebelum dan sesudah diberikan latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender. Hal ini mengindikasikan adanya pengaruh latihan teknik relaksasi pernapasasn Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] menggunakan aromaterapi lavender terhadap intensitas nyeri akibat luka post sectio caesarea dengan p-value < 0.05 baik terhadap intensitas skala nyeri dan berkurangnya nyeri yang dialami ibu post sectio caesarea dapat diatasi. SARAN Diharapkan bagi ibu post sectio caesarea dapat memahami tentang latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender terhadap intensitas nyeri akibat luka post sectio caesarea. Informasi yang telah diterima dapat dipraktekkan secara mandiri oleh ibu dalam kehidupan sehari � hari sehingga ketika terjadi nyeri, ibu dapat mengontrol sensasi nyeri dan aktivitas ibu tidak terganggu. Diharapkan dapat menjadi masukan bagi dokter, bidan dan perawat terhadap program pelayanan ibu post sectio caesarea tentang penanganan nyeri secara non farmakologi dengan latihan teknik relaksasi pernapasan menggunakan aromaterapi lavender. Dengan adanya kombinasi antara farmakologi yang diberikan dan non farmakologi dapat membantu mempercepat proses penyembuhan. Peneliti menyarankan untuk dilakukan penelitian lebih lanjut tentang perbandingan latihan teknik relaksasi pernapasan menggunakan aromaterapi dengan metode yoga untuk perawatan luka post sectio caesarea. Peneliti juga menyarankan untuk pengukuran dengan skala nyeri lebih akurat. UCAPAN TERIMA KASIH Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] Ucapan terima kasih penulis sampaikan kepada Rumah Sakit Al Islam Bandung yang telah member izin penelitian. DAFTAR PUSTAKA Anggorowati, dkk. 2007. Efektifitas Pemberian Intervensi Spiritual �Spirit Ibu� terhadap Nyeri Post Sectio Caesarean (SC) pada RS Sultan Agung dan RS Roemani Semarang. Journal Media Ners Vol 1, No 1, Tahun 2007: 10 � 15. Atkinson, R,et al. 2003. Penghantar Psikologi edisi 8 jilid 2. Jakarta: Penerbit Erlangga. Batubara, dkk. 2008. Hubungan Pengetahuan, Nyeri Pembedahan Sectio Caesaria dan Bentuk Puting dengan Pemberiann Air Susu Ibu Pertama Kali Pada Ibu Post Partum. Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing), Volume 3 No.2 Juli 2008 54. Bobak, Lowdermilk, Jansen. 2004. Buku Ajar Keperawatan Maternitas. Edisi 4. Jakarta : EGC. Cunningham, F. Gary et al. 2006. Obstetric Williams Edisi 21 vol.1. Jakarta: EGC. Hale, G. 2008. Lavender � nature�s aid to stress relief. www.aromatherapy- stressrelief. com. ( diakses tanggal 22 Juni 2012). Handerson, C. 2005. Buku Ajar Konsep Kebidanan. Jakarta: EGC. Hutasoit, A.S. 2002. Panduan Praktis Aromatherapy Untuk Pemula. Jakarta: PT Gramedia Pustaka Utama. Indiarti, M.T (2009). Panduan Lengkap Kehamilan, Persalinan dan Perawatan Bayi. Jogyakarta : Diglossia Media. Kim T et al. ( 2007). Treatment with Lavender Aromatherapy in the Post- Anesthesia Care Unit reduces. Opioid Requirements of Morbidly Obese Patients Undergoing Laparoscopic Adjustable. Gastric Banding. Obesity Surgery 2007; 17: 920-925. Mochtar Rustam, 1998. Buku Acuan Pelayanan Nasional: Pelayanan Kesehatan Maternal dan Neonatal. Jakarta: Yayasan Bina Pustaka Sarwono Prawihardjo. Notoadmodjo. 2003.Ilmu Kesehatan Masyarakat. Jakarta: PT Rineka Cipta. Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] Padilla, et al. 2008. Risk Factors in Cesarean Section. Ginecol Obstet Mex Article in Spanish. 2008 Jul;76(7):392-7. Potter, Perry, 2006. Fundamental Keperawatan, Konsep, Proses dan Praktik, Edisi 4, Volume 2. Jakarta : EGC. _________. 2005. Fundamental Keperawatan, Konsep, Proses dan Praktik, Edisi 4, Volume 2. Jakarta : EGC. Price, Shirley. 1997. Aromaterapi Bagi Profesi Kesehatan. Jakarta: EGC. Priharjo, R. 2003. Perawatan Nyeri. Jakarta: EGC. Shinobi. 2008. Pijat Aromaterapi. http://id.88db.com/id/Discussion/Discussion_ reply.page/Health_Medical??Discl D=1309. (diakses tanggal 14 Juli 2012). Smeltzer, S. C, & Bare, B.G. (2001). Buku ajar keperawatan medikal bedah Brunner and Suddarth. (8 th edition). Jakarta: EGC. Sulistyowati, D. 2009. Efektifitas Terapi Aroma Lavender Terhadap Tingkat Nyeri dan Kecemasan Persalinan Primipara Kala I di Rumah Sakit dan Klinik Bersalin Purwokerto. Walley, J., Simkin, P., dan Keppler, A. (2008). Panduan Praktis Bagi Calon Ibu : Kehamilan dan Persalinan. Jakarta : PT. Bhuana Ilmu Populer. Ratna Pratiwi Fakultas Ilmu Keperawatan Universitas Padjadjaran (Jl.Raya Bandung-Sumedang KM.21 Jatinangor-Sumedang) Email:
[email protected] ISSN 2354-7642 Jurnal Ners dan Kebidanan Indonesia JOURNAL NERS Tersedia online pada: AND MIDWIFERY INDONESIA http://ejournal.almaata.ac.id/index.php/JNKI Aromaterapi Lavender dapat Menurunkan Intensitas Nyeri Perineumpada Ibu Post Partum Wiwin Widayani DIII Kebidanan Poltekkes Kemenkes Bandung Jalan Pajajaran No.56, Pasir Kaliki, Cicendo, Kota Bandung, Jawa Barat 40171 Email:
[email protected] Abstrak Nyeri perineum dapat memengaruhi kemampuan wanita untuk mobilisasi sehingga dapat menimbulkan komplikasi seperti perdarahan post partum. Trauma pada perineum juga menimbulkan rasa tidak nyaman dan nyeri saat melakukan hubungan seksual. Karena itu, penanganan nyeri perineum ini penting dilakukan. Saat ini penanganan yang sering digunakan yaitu terapi komplementer aromaterapi dengan minyak essensial lavender, karena lavender mempunyai sifat antikonvulsan, antidepresi, anxiolytic, dan menenangkan. Aromaterapi akan menstimulasi hipotalamus untuk mengeluarkan mediator kimia yang berfungsi sebagai penghilang rasa sakit dan menimbulkan perasaan bahagia. Tujuan penelitian ini adalah untuk mengetahui pengaruh aromaterapi lavender terhadap intensitas nyeri luka jahitan perineum pada ibu post partum. Penelitian ini merupakan quasi eksperiment pre and post control pada ibu nifas yang berada di Bidan Praktik Mandiri Wilayah Kota Bandung. Pengambilan sampel penelitian ini menggunakan teknik consecutive sampling. Data diambil dengan menggunakan instumen yang diadaptasi dari Visual Analog Scale (VAS) dengan analisis uji wilcoxon. Hasil penelitian menunjukkan ada penurunan nyeri sebelum dan setelah pemberian aromaterapi lavender secara inhalasi (Z=-3,77) dengan p-value 0,001. Aromaterapi lavender dapat menjadi alternatif terapi komplementer untuk menurunkan nyeri pada ibu post partum akan tetapi diperlukan penelitian lebih lanjut dengan responden yang lebih banyak. Kata Kunci: aromaterapi lavender, nyeri perineum Lavender Aromatherapy Reduced the Intensity of Perineal Pain among Post Partum Women . Abstract Perineals pain affects woman ability to mobilize so that it can cause complications such as post-partum hemorrhagic. Trauma to the perineum also cause discomfort and dyspareunia, therefore, perineal pain management is important. Currently the handling used to relieve pain is complementary therapy aromatherapy with essential oils of lavender, because lavender has the properties of anticonvulsant, antidepressant, anxiolytic, and also soothing. Aromatherapy stimulates the hypothalamus to secrete chemical mediators that serve as pain relievers and give rise to feelings of happiness. The purpose of this study was to determine the effect of lavender aromatherapy to the perineal pain intensity in post partum women. This study was a quasi experiment pre and post non random control in postpartum women at Bidan Praktik Mandiri in Bandung. This study used was consecutive sampling technique. The data were taken using the instrument adapted from a Visual Analog Scale (VAS) and analyzed by the wilcoxon signed rank test. The result showed that there was a decrease in pain intensity before and after the administration of inhaled lavender aromatherapy (Z=-3.77) with p-value 0.001. Lavender aromatherapy can be a complementary alternative therapy to reduce pain in postpartum women but more research necessary is needed with more respondents. Keywords: lavender aromatherapy, perineum pain Info Artikel: Artikel dikirim pada 21 September 2016 Artikel diterima pada 31 Oktober 2016 DOI : http://dx.doi.org/10.21927/jnki.2016.4(3).123-128 Aromaterapi Lavender dapat Menurunkan Intensitas Nyeri Perineum pada Ibu Post Partum 123 PENDAHULUAN Tanpa memperhatikan apakah perineum mengalami trauma atau tidak, seorang ibu cenderung merasakan adanya memar di sekitar vagina dan jaringan perineum selama beberapa hari setelah persalinan. Ibu yang mengalami laserasi perineum akan merasakan nyeri selama beberapa hari sampai penyembuhan terjadi (1). Padabeberapaorang,nyeridapatmengganggu dibanding gangguan akibat penyakit yang lain. Setelah melahirkan secara pervaginam, seorang ibu sering melaporkan nyeri dan trauma pada perineum. Nyeri perineum merupakan hal yang fisiologis pada ibu post partum, akan tetapi nyeri ini memengaruhi kemampuan wanita untuk mobilisasi sehingga dapat menimbulkan komplikasi seperti perdarahan post partum. Nyeri perineum akibat adanya trauma seperti adanya laserasi perineum dapat menyebabkan rasa tidak nyaman dan dispareunia. Di Rumah Sakit Royal Victoria Australia dilaporkan bahwa 90% wanita mengalami nyeri perineum. Nyeri dirasakan ketika berjalan (33%), duduk (39%), dan tidur (45%) (2). Hasil penelitian menjelaskan bahwa sebagian besar wanita menggunakan analgesia untuk mengatasi rasa sakit tersebut dengan menggunakan obat analgetik dan ice pack (69%), oral analgesik (75%) (2). Hal tersebut membuktikan bahwa nyeri perineum sangat mengganggu bagi sebagian besar wanita. Apabila kekhawatiran dan nyeri perineum berlangsung lama, maka dapat berdampak negatif terhadap fungsi dan pengalaman awal menjadi seorang ibu. Oleh karena itu, penanganan nyeri perineum ini penting untuk dilakukan. Penanganan untuk mengurangi nyeri perineum dapat dilakukan secara farmakologi dan non farmakologi. Namun penggunaan secara farmakologi sering menimbulkan efek samping dan kadang tidak memiliki kekuatan efek yang diharapkan. Aromaterapi digunakan sebagai salah satu alternatif penanganan nyeri non farmakologik. Berbagai macam aroma terapi yang dapat digunakan antara lain cendana, kemangi, kayumanis, kenanga, sitrus, melati, cengkih, lavender, mawar, jasmine. Saat ini penanganan yang sering digunakan untuk mengurangi rasa nyeri yaitu terapi komplementer aromaterapi dengan minyak essensial lavender, karena lavender mempunyai sifat-sifat antikonvulsan, antidepresi, anxiolytic, dan bersifat menenangkan (3). Saat aromaterapi dihisap, zat aktif yang terdapat di dalamnya akan merangsang hipotalamus (kelenjar hipofise) untuk mengeluarkan hormon endorpin. Endorpin diketahui sebagai zat yang menimbulkan rasa tenang, relaks dan bahagia. Di samping itu, zat aktif berupa linaool dan linalyl acetate yang terdapat dalam lavender berefek sebagai analgetik (4,5). Banyak penelitian melaporkan pengaruh aromaterapi lavender terhadap penurunan nyeri, tetapi pengaruh aromaterapi lavender terhadap nyeri perineum belum banyak. Vakilian melaporkan bahwa pemberian aromaterapi lavender dapat mengurangi nyeri perineum pada 60 ibu nifas yang mengalami laserasi spontan dan episiotomi, 40% di antaranya dilaporkan tidak merasakan sakit. Dale & Cornwell melaporkan nyeri perineum berkurang pada 635 ibu post partum yang mandi dengan menambahkan minyak lavender (6). Oleh karena itu, perlu dilakukan penelitian pengaruh aromaterapi lavender terhadap penurunan nyeri luka jahitan perineum ibu post partum. BAHAN DAN METODE Penelitian ini dilakukan dengan menggunakan penelitian quasi experiment dengan rancangan one group pre dan post test. Tempat penelitian adalah Bidan Praktik Mandiri (BPM) yang ada di wilayah Kota Bandung. Penelitian dilakukan mulai dari Bulan Mei sampai September 2015, dengan jumlah sampel 28 orang. Teknik pengambilan sampel pada penelitian ini adalah dengan non probability sampling berupa teknik consecutive sampling yaitu dengan memilih sampel yang memenuhi kriteria penelitian sampai kurun waktu tertentu sehingga jumlah sampel terpenuhi. Kriteria inklusi pada penelitian ini adalah ibu post partum hari ke 1, ibu post partum yang melahirkan normal (pervaginam) dan mengalami rupture derajat 2, ibu post partum yang mengalami luka jahitan perineum. Sedangkan kriteria eksklusinya yaitu ibu post partum yang melahirkan dengantindakanoperasiatauvakum,ibu post partum yang mengalami vaginitis, hematoma dan abses di perineum,ibu post partumyangmemilikiriwayatalergi obat, ibu post partum yang memiliki penyakit asma. Intervensi dilakukan setelah 2 jam dilakukan penjahitan perineum. Setelah mengisi kuesioner pretest, reponden diberikan intervensi aromaterapi lavender inhalasi dalam kurun waktu menit ke 124 Wiwin Widayani, 2016. JNKI, Vol. 4, No. 3, Tahun 2016, 123-128 10, 30 dan 60, aromaterapi diberikan selama 10 menit. Kemudian dilakukan posttest seiring dengan observasi masa nifas 2 jam, dengan cara memeriksa luka jahitan perineum menggunakan pinset anatomis. Saat diperiksa luka jahitan, peneliti melihat reaksi wajah responden. Instrumen yang digunakan yaitu Visual Analogue Scala (VAS) dengan skala nyeri 0-10, dengan batasan kategori nyeri diadaptasi ke dalam Bahasa Indonesia, yaitu tidak nyeri (0); nyeri ringan (1-3); rasa nyeri seperti rasa gatal, rasa tersetrum, melilit, terpukul, perih, nyut-nyutan, kram; nyeri sedang (4-7); rasa nyeri seperti nyut-nyutan/ kram; nyeri berat (8-9): sangat nyeri, sulit bergerak tapi masih terkontrol; dan nyeri sangat berat (10): sangat nyeri, sulit bergerak sampai tidak terkontrol seperti menangis, menjerit. Bahan yang digunakan adalah uap minyak lavender dengan konsentrasi 100%, diberikan 4-5 tetes dilarutkan dalam 200 ml air, diberikan secara inhalasi melalui vaporizer atau alat listrik. Sebelum inhalasi, cawan tungku aromaterapi yang telah diberikan air ditunggu sampai hangat baru diteteskan essens aromaterapi. Jarak antara tungku dengan responden kurang 30 cm. Setelah tercium wangi aromaterapi, pasien diminta relaks dan menghirup wangi aromaterapi selama 10 menit. Responden dikondisikan dalam ruangan dengan ukuran antara 10-16 m2 dan tidak banyak ventilasi udara. Analisis data yang digunakan analisis univariat dan bivariat. Analisis bivariabel sebelum dan setelah diberikan perlakuan digunakan uji wilcoxon. HASIL DAN BAHASAN Berdasarkan Tabel 1 dapat diketahui bahwa karakteristik responden berdasarkan umur terbanyak adalah 20-35 tahun (71,4%) sedangkan karakteristik responden berdasarkan pekerjaan sebanyak 92,9% tidak bekerja. Berdasarkan pendidikan responden, terbanyakpadapendidikanSMA(39,3%). Berdasarkan riwayat melahirkan, responden terbanyak pada pada riwayat melahirkan =2 kali (57,1%). Tabel 1. Distribusi Frekuensi Nyeri Luka Jahitan Perineum Berdasarkan Karakteristik Responden Karakteristik n % Usia < 20 Tahun 7 25 20-35 tahun 20 71,4 >35 tahun 1 3,6 Pekerjaan Tidak bekerja 26 92,9 Bekerja 2 7,1 Pendidikan SD 3 10,7 SMP 8 28,6 SMA 11 39,3 Perguruan Tinggi 6 21,4 Paritas Melahirkan 1 kali 12 42,9 Melahirkan > 2 kali 16 57,1 Jumlah 28 100 Sumber: Data Primer Tahun 2015 Tabel 2 di bawah ini merupakan frekuensi intensitas nyeri luka jahitan perineum sebelum dan sesudah intervensi. Tabel 2. Distribusi Frekuensi Intensitas Nyeri Luka Jahitan Sebelum dan Sesudah Intervensi Intensitas Nyeri Sebelum n % Sesudah n % Tidak Nyeri 2 7,1 7 25 Nyeri Ringan 6 21,4 11 39,3 Nyeri Sedang 10 35,7 9 32,1 Nyeri Berat 8 28,6 1 3,6 Nyeri Sangat Berat 2 7,1 0 0 Jumlah 28 28 Sumber: Data Primer Tahun 2015 Berdasarkan Tabel2 diketahui bahwa intensitas nyeri sebelum diberikan intervensi paling banyak berada pada nyeri sedang (35,7%). Setelah diberikan intervensi, intensitas nyeri paling banyak menjadi nyeri ringan (39,3%) Tabel 3 merupakan tabel perbedaan intensitas nyeri luka jahitan perineum sebelum dan sesudah diberikan aromaterapi lavender. Tabel 3. Perbedaan Intensitas Nyeri Luka Jahitan Perineum Sebelum dan Sesudah Intervensi Sebelum Sesudah Skor Intensitas Perlakuan Perlakuan p-value Nyeri Perineum (n=28) (n=28) Median (Rentang) 3,00 (1-5) 2,00(1-4) <0,001* Sumber: Data Primer Tahun 2015 *Uji Wilcoxon (Z= -3,77) Aromaterapi Lavender dapat Menurunkan Intensitas Nyeri Perineum pada Ibu Post Partum 125 Pada Tabel 3 dapat diketahui bahwa nilai median dan rentang dari skor intensitas nyeri luka perineum setelah perlakuan menjadi lebih rendah dibandingkan sebelum perlakuan. Berdasarkan hasil uji statistik nilai p<0,05 sehingga terdapat perbedaan skor pada kelompok responden sebelum perlakuan dan setelah perlakuan. Oleh karena itu dapat diasumsikan bahwa pemberian aromaterapi lavender berpengaruh terhadap penurunan intensitas nyeri luka perineum. Nyeri luka perineum akan dirasakan setelah persalinan sampai beberapa hari pasca persalinan. Bagi seorang perempuan kekuatan otot perineum sangat penting, karena robekan perineum yang terjadi selama proses persalinan dapat menyebabkan melemahnya otot-otot dasar panggul. Selain itu, robekan perineum dapat menyebabkan rasa tidak nyaman dan dispareunia. Hasil penelitian didapatkan bahwa responden mengalami nyeri sedang (35,7%). Nyeri yang dirasakan ini dapat terjadi karena adanya proses penghantaran nyeri dari sel syaraf aferen atau neuron sensori, serabut konektor atau interneuron dan sel saraf eferen atau neuron motorik yang dihantarkan ke otak, sehingga dipersepsikan tubuh menjadi rasa nyeri. Nyeri perineum dapat terjadi setelah persalinan pervaginam akibat laserasi spontan pada saat bayi lahir dan dapat diperparah apabila terdapat robekan padaperineumyangdisebabkantindakanepisiotomi. Tindakan ini akan memerlukan penjahitan dan dengan penjahitan tersebut dapat menyebabkan nyeri pada daerah luka jahitan. Sebanyak 33% wanita mengalami nyeri perineum karena tindakan episiotomi dan 52% merupakan laserasi spontan (7). Pengurangan rasa nyeri luka jahitan perineum padaibu post partumdilakukandenganberbagaicara, salah satunya dengan pemberian inhalasi melalui aromaterapi lavender. Berdasarkan hasil penelitian bahwa terdapat perbedaan signifikan intensitas nyeri antara kelompok perlakuan dan kelompok kontrol dengan p-value 0,01. Sesuai hasil penelitian Stea Susana menunjukkan bahwa terapi esensial minyak lavender berpengaruh secara positif terhadap kecemasan insomnia dan mengontrol rasa sakit (8). Dengan demikian aromaterapi lavender dapat menjadi salah satu alternatif penanganan nyeri luka perineum yang dapat mengakibatkan kondisi fisik maupun psikologis ibu menjadi lebih baik. Begitu juga hasil penelitian Salamati didapatkan bahwa rasa sakit sebelum dan setelah menghirup minyak esensial lavender berpengaruh secara signifikan terhadap pengurangan rasa sakit dengan p-value <0,05 (9). Menurut Dochterman, aromaterapi adalah pemberian minyak esensial melalui metode massase, salep topikal, inhalasi, mandi kompres (panas, dingin) untuk mengurangi nyeri dan dapat menimbulkan efek relaksasi dan terapi pengobatan (7). Bentuk aromaterapi yang banyak digunakan untuk mengurangi rasa nyeri serta memiliki sifat antiseptiknya adalah lavender. Penelitian yang dilakukan Dale & Cornwell pada 635 wanita yang pada kelompok pertama ditambahkan minyak lavender murni pada air mandi mereka sebanyak 6 tetes pada hari ke 10 pertama pascanatal. Pada hari kesepuluh wanita dan bidan menyelesaikan kuesioner mengenai nyeri perineum. Data yang diperoleh menunjukkan bahwa 90% ibu melaporkan merasa lebih baik setelah mandi menggunakan minyak lavender dan tidak ditemukan efek samping (10). Kristanti menjelaskan bahwa molekul dan partikel lavender saat dihirup akan masuk melalui hidung, kemudian diterima oleh reseptor saraf sebagai signal yang baik dan kemudian diinterpretasikan sebagai bau yang menyenangkan, dan akhirnya sensori bau tersebut masuk serta memengaruhi sistem limbic sebagai pusat emosi seseorang, sehingga saraf dan pembuluh darah perasaan akan semakin relaks dan akhirnya rasa nyeri berkurang (11). Dijelaskan juga oleh Pratiwi bahwa penurunan nyeri dengan aromaterapi lavender mengacu pada konsep gate control yang terletak pada fisiologi mekanisme penghantaran impuls nyeri yang terjadi saat sistem pertahanan dibuka, dan sebaliknya penghantaran impuls nyeri dapat dihambat saat sistem pertahanan ditutup. Aromaterapi lavender merupakan salah satu upaya untuk menutup sistem pertahanan tersebut. Selain itu, aromaterapi lavender memengaruhi kelancaran sirkulasi darah, sehingga suplai nutrisi ke jaringan luka tercukupi dan proses penyembuhan akan lebih cepat (12).Saat aromaterapi dihisap, zat aktif yang terdapat di dalamnya akan merangsang hipotalamus (kelenjar hipofise) untuk mengeluarkan hormon endorpin. Endorpin diketahui sebagai zat yang menimbulkan rasa tenang, relaks, dan bahagia. Di samping itu, zat aktif berupa linaool dan linalyl acetate yang terdapat dalam lavender berefek sebagai analgetik (4,5). Karlina dkk juga menjelaskan bahwa pemberian aromaterapi lavender terbukti dapat menurunkan 126 Wiwin Widayani, 2016. JNKI, Vol. 4, No. 3, Tahun 2016, 123-128 intensitas nyeri persalinan fisiologis kala satu fase aktif. Begitu juga Kartika dkk menyebutkan bahwa terdapat perbedaan signifikan pada intensitas nyeri persalinan normal kala satu, sebelum dan sesudah diberikan lilin aromaterapi lavender. Hal ini membuktikan bahwa efek aromaterapi lavender yang memberikan rasa tenang dan analgetik sangat berpengaruh terhadap penurunan rasa nyeri. Seperti yang telah dijelaskan sebelumnya bahwa zat kimia yang dihasilkan dari hormon endorpin sebagai akibat rangsangan hipotalamus oleh aromaterapi lavender, dapat menghasilkan rasa tenang, rasa bahagia dan relaks, serta melemasakan otot-otot yang tegang akibat rasa nyeri, salah satunya melemaskan otototot perineum yang tegang karena rasa nyeri luka laserasi (4,5,13,14). SIMPULAN DAN SARAN Terdapat penurunan intensitas nyeri luka jahitan perineum sebelum dan setelah diberikan aromaterapi lavender. Aromatepi lavender berpengaruh secara signifikan terhadap penurunan nyeri luka jahitan perineum pada ibu post partum dengan p-value 0,01. Inhalasi aromaterapi lavender dapat digunakan sebagai alternatif terapi komplementer pada ibu post partum dengan luka jahitan perineum. Diperlukan penelitan lebih lanjut dengan sampel yang lebih banyak dengan responden yang tidak hanya memiliki luka jahitan perineum derajat dua. RUJUKAN 1. Fraser DM, Cooper MA. Myles Buku Ajar Bidan. Jakarta: EGC; 2009. 2. East CE, Sherburn M, Nagle C, Said J, Forster D. Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery [Internet]. 2012 Feb [cited 2015 Sep 10];28(1):93�7. Available from: http://linkinghub. elsevier.com/retrieve/pii/S0266613810001889. 3. Koensoemardiyah. Aromaterapi untuk Kesehatan dan Kecantikan. Yogyakarta: Lily Publisher; 2009. 4. Tournaire M, Theau-Yonneau A. Complementary and Alternative Approaches to Pain Relief during Labor. Evidence-Based Complement Altern Med [Internet]. 2007 [cited 2015 Jan 1];4(4):409�17. Available from: http://www.hindawi.com/journals/ ecam/2007/256475/abs/ 5. Woollard AC, Tatham KC, Barker S. The influence of essential oils on the process of wound healing: a review of the current evidence. J Wound Care [Internet]. 2007 Jun;16(6):255�7. Available from: http://www.magonlinelibrary.com/doi/ abs/10.12968/jowc.2007.16.6.27064. 6. Vakilian K, Atarha M, Bekhradi R, Chaman R. Healing advantages of lavender essential oil during episiotomy recovery: A clinical trial. Complement Ther Clin Pract [Internet]. 2011 Feb;17(1):50�3. Available from: http://linkinghub. elsevier.com/retrieve/pii/S1744388110000381 7. Dochterman J. Nursing intervention Classification (NIC) fourth edition. USA: Mosby; 2004. 8. Stea S, Beraudi A, De Pasquale D. Essential Oils for Complementary Treatment of Surgical Patients: State of the Art. Evidence-Based Complement Altern Med [Internet]. 2014;2014:1�6. Available from: http://www.hindawi.com/journals/ ecam/2014/726341/ 9. Salamati A, Mashouf S, Sahbaei F, Mojab F. Effects of Inhalation of Lavender Essential Oil on Open-heart Surgery Pain. Iran J Pharm Res IJPR [Internet]. 2014;13(4):1257�61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25587315. 10. Koulivand PH, Khaleghi Ghadiri M, Gorji A. Lavender and the Nervous System. Evidence- Based Complement Altern Med [Internet]. 2013;2013:1�10. Available from: http://www. hindawi.com/journals/ecam/2013/681304/ 11. Kristanti EE. Pengaruh Aropmaterapi Lavender Terhadap Penurunan Derajat Kecemasan pada Lansia di Panti Wredha St Yoseph Kediri. J Penelit Stikes RS Baptis Kediri [Internet]. 2010;3(2):94� 100. Available from: http://puslit2.petra.ac.id/ ejournal/index.php/stikes/article/view/18399. 12. Pratiwi R, Ermiati, Widiasih R. Penurunan Intensitas Nyeri Akibat Luka Post Sectio Caesarea Setelah Dilakukan latihan Teknik Relaksasi Pernapasan Menggunakan Aromaterapi Lavender di Rumah Sakit Al Islam Bandung. Students e-journals [Internet]. 2012;1(1):1�15. Available from: http:// jurnal.unpad.ac.id/ejournal/article/view/711. 13. Karlina SD, Reksohusodo S, Widayati A. Pengaruh Aromaterapi Lavender secara Inhalasi terhadap Penurunan Intensitas Nyeri Persalinan Fisiologis pada Primipara Inpartu Kala Satu Fase Aktif di BPM Fetty Fathiyah Kota Mataram. Maj Kesehat Fak Kedokt Univ Brawijaya [Internet]. Aromaterapi Lavender dapat Menurunkan Intensitas Nyeri Perineum pada Ibu Post Partum 127 2015;2(2). Available from: http://majalahfk.ub.ac. id/index.php/mkfkub/article/view/59. 14. Kartika R, Susilo J, Lestari P. Efek Lilin Aromaterapi Lavender Terhadap Perubahan Intensitas Nyeri Persalinan Normal Kala I Fase Aktif. ejurnal Ngudi Waluyo [Internet]. 2015;7(24). Available from: http://ejournalnwu.ac.id/article/ view/1435905534. 128 Wiwin Widayani, 2016. JNKI, Vol. 4, No. 3, Tahun 2016, 123-128 PERBEDAAN TINGKAT NYERI SEBELUM DAN SESUDAH PEMBERIAN AROMATHERAPI LAVENDER PADA IBU POST SECTIO CAESAREA DI RSUD AMBARAWA Prita Swandari Program Studi Diploma IV Kebidanan STIKES Ngudi Waluyo Ungaran ABSTRACT Background: Childbirth with sectio caesarea is childbirth with a tear abdomen to get a fetus. The process will cause pain as a result of surgery and recovery trough the seams. The post-SC surgical wound in the abdomen area will cause pain. Lavender aromatherapy is a non pharmacological treatment for the pain. The of aromatherapy lavender is able in increasing relaxation, lowering stress, and reducing pain. The purpose of this study is to find the differences in levels of pain before and after getting lavender aromatherapy in the mothers with post-SC at Ambarawa Public Hospital. Method: This was a quasi-experimental study with the samples of 26 patients with post-SC sampled by using accidental sampling technique. The levels of pain were measured by using numerical scales. The bivariate analysis used the Wilcoxon test. Results: The results of this study indicated that there were 21 respondents (80.8%) who have pain in the category of medium, and 5 respondents (19:20%) who had pain in the category of mild, whereas after the lavender aromatherapy given indicated that there were 20 respondents (76.92%) who have pain in the category of mild, and 6 respondents (23.1%) who had pain in the category of medium. The bivariate analysis indicated that there was a difference in the levels of pain in the patients with post- SC before and after getting lavender aromatherapy with p-value of 0.000 < a = 0.05. Advice: From the research that can be used as reference to to condiser aromatherapi of lavender as therapi to reduce pain in patients post sectio caesarea. Keywords : Levels of sectio caesarea pain, Lavender aromatherapy PENDAHULUAN Persalinan normal merupakan proses dari mulai mulesnya ibu sampai pada keluarnya bayi dengan kondisi kepala dahulu melalui vagina, dengan lama persalinan kurang dari 24 jam (Whalley, 2008). Proses ini kadang tidak berjalan semestinya dan janin tidak dapat lahir secara normal karena beberapa faktor, yaitu komplikasi kehamilan, disproporsi sefalo-pelvik, partus lama, ruptur uteri, cairan ketuban yang tidak normal, kepala panggul. Keadaan tersebut perlu tindakan medis berupa operasi sectio caesarea (Padilla, et al.,2008). Persalinan secara sectio caesarea dapat memungkinkan terjadinya komplikasi lebih tinggi daripada melahirkan secara pervaginam atau persalinan normal. Komplikasi yang bisa timbul pada ibu post sectio caesarea seperti nyeri pada daerah insisi, potensi terjadinya thrombosis, potensi terjadinya penurunan kemampuan fungsional, penurunan elastisitas otot, perut dan otot dasar panggul, perdarahan, luka kandung kemih, infeksi, bengkak pada ekstremitas bawah, dan gangguan laktasi (Rustam M, 2008) Pada proses operasi digunakan anestesi agar pasien tidak nyeri pada saat dibedah. Namun setelah operasi selesai dan pasien mulai sadar, akan merasakan nyeri di daerah sayatan yang membuat sangat terganggu (Whalley, dkk 2008). Menurut Rustam M (2008) dalam Pratiwi (2012) nyeri yang dikeluhkan pasien post operasi SC yang berlokasi pada daerah insisi, disebabkan oleh robeknya jaringan pada dinding perut dan dinding uterus. Rasa nyeri yang dirasakan post Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender pada Ibu Post Sectio Caesarea di RSUD Ambarawa SC akan menimbulkan berbagai masalah, salah satunya masalah laktasi. Rasa nyeri tersebut akan menyebabkan pasien menunda pemberian ASI sejak awal pada bayinya, karena rasa tidak nyaman dan peningkatan tingkat nyeri setelah operasi (Batubara dkk, 2008). Ibu post operasi SC akan merasakan nyeri, dan dampak dari nyeri akan mengakibatkan mobilisasi ibu menjadi terbatas, Activity of Daily Living (ADL) terganggu, bonding attachment (ikatan kasih sayang) dan Inisiasi Menyusui Dini (IMD) tidak terpenuhi karena adanya peningkatan tingkat nyeri apabila ibu bergerak. Hal ini mengakibatkan respon ibu terhadap bayi kurang, sehingga ASI sebagai makanan terbaik bagi bayi dan mempunyai banyak manfaat bagi bayi maupun ibunya tidak dapat diberikan secara optimal (Purwandari, 2009). Penanganan yang sering digunakan untuk menurunkan nyeri post sectio caesarea berupa penanganan farmakologi. Pengendalian nyeri secara farmakologi efektif untuk nyeri sedang dan berat. Namun demikian pemberian farmakologi tidak bertujuan untuk meningkatkan kemampuan klien sendiri untuk mengontrol nyerinya (Van Kooten, 1999 dalam Anggorowati dkk., 2007). Sehingga dibutuhkan kombinasi farmakologi untuk mengontrol nyeri dengan non farmakologi agar sensasi nyeri dapat berkurang serta masa pemulihan tidak memanjang (Bobak, 2004). Pengendalian nyeri non-farmakologi menjadi lebih murah, simpel, efektif, tanpa efek yang merugikan, dan ibu dapat mengendalikan sendiri keluhan nyerinya (Potter, 2005). Manajemen nonfarmakologi yang sering diberikan antara lain yaitu dengan meditasi, latihan autogenic, latihan relaksasi progresif, guided imagery, nafas ritmik, operant conditioning, biofeedback, membina hubungan terapeutik, sentuhan terapeutik, stimulus kutaneus, hipnosis, musik, accupresure, aromatherapi (Sulistyo, 2013). Aromatherapi merupakan salah satu therapi non farmakologis untuk mengurangi nyeri persalinan, yaitu sebuah terapi komplementer yang melibatkan penggunaan wewangian berasal dari minyak esensial. Minyak esensial dapat dikombinasikan dengan base oil (minyak campuran obat) yang dapat dihirup atau di massase ke kulit yang utuh (Brooker, 2009). Aromatherapi digunakan untuk menyembuhkan masalah pernafasan, rasa nyeri, gangguan pada saluran kencing, gangguan pada alat kelamin, dan juga masalah mental dan emosional. Hal ini terjadi karena aromatherapi mampu memberikan sensasi yang menenangkan diri dan otak, serta stress yang dirasakan (Laila 2011). Pengaruh aromaterapi terhadap kenyamanan dapat diukur dengan melihat berbagai indikator yang memperlihatkan kenyamanan. Indikator tersebut adalah interpretasi terhadap aromaterapi itu sendiri akan menunjukan respon emosi fight or flight, interpretasi terhadap rasa nyaman yang di dapat dari efek aromaterapi, pernyataan bahwa aromaterapi meningkatkan kinerja, peningkatan konsentrasi, pikiran lebih tenang, jiwa menjadi sejuk (Price, 2007). Respon non verbal menunjukan kenyamanan (tidak ada kerut muka, tidak ada gerakan menjauhkan diri, tidak ada pengatupan kelopak mata, tidak ada pemalingan wajah/seluruh badan) (Atkinson, R 2009). Menurut Dr. Alan Huck (Neurology Psikiater dan Direktur Pusat Penelitian Bau dan Rasa), aroma berpengaruh langsung terhadap otak manusia, mirip narkotika. Hidung memiliki kemampuan untuk membedakan lebih dari 100.000 bau yang berbeda yang sangat berpengaruh pada otak yang berkaitan dengan suasana hati, emosi, ingatan, dan pembelajaran. Dengan menghirup aroma lavender maka akan meningkatkan gelombang-gelombang alfa di dalam otak dan gelombang inilah yang membantu kita untuk merasa rileks (Simkin, 2008). Bunga yang digunakan untuk aromatherapi adalah lavendula atau biasa disebut lavender. Lavender adalah tumbuhan berbungan dalam suku lamiaceae yang memiliki 25-30 spesies. Lavender berasal dari wilayah selatan laut tengah Afrika tropis dan ke timur sampe india. Saat ini lavender telah ditanam dan dikembangkan di seluruh dunia. Tanaman cantik dan berbungan kecil berwarna ungu ini memiliki khasiat yang sangat bermanfaat bagi manusia. Minyak aromatherapi lavender dikenal sebagai minyak penenang, efek sedative lavendula angustifolia terjadi karena adanya senyawa-senyawa coumarin dalam minyak tersebut (Ogan, 2005). Secara teoritis aromatherapi lavender bekerja dengan mempengaruhi tidak hanya Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender pada Ibu Post Sectio Caesarea di RSUD Ambarawa fisik tetapi juga tingkat emosi (Balkam, 2004). Kandungan lavender oil yang terdiri dari linalool, linalyl acetate, dan 1,8 -cincole dapat menurunkan, mengendorkan, dan melemaskan secara spontan ketegangan pada tikus yang mengalami spasme pada otot intestinalnya. Mekanisme massage pada tubuh dapat menstimulasi produksi endhorpin di otak, sehingga dapat memblokir transmisi stimulus nyeri. Sedangkan apabila minyak aromatherapi masuk ke rongga hidung melalui penghirupan langsung akan bekerja lebih cepat karena molekul-molekul minyak esensial mudah menguap oleh hipotalamus karena aroma tersebut diolah dan dikonversikan oleh tubuh menjadi suatu aksi dengan pelepasan subtansi neurokimia berupa zat endorphin dan serotinin sehingga berpengaruh langsung pada organ penciuman dan dopersepsikan oleh otak untuk memberikan reaksi yang membuat perubahan fisiologis pada tubuh., pikiran, jiwa, dan menghasilkan efek menenangkan pada tubuh (Nurachman, 2004). Zat endorphin merupakan zat kimia yang diproduksi tubuh hasil dari stimulasi eksternal dan menghasilkan perasaan tenang, senang, rileks, terangsang, serta melemaskan otot-otot yang tegang seperti rasa sakit, gembira, dan pengerahan tenaga secara fisik. Sementara itu zat serotinin adalah neurotransmiter yang mempengaruhi suasana hati, pola tidur, dan selera makan. Aromatherapi lavender dihirup selama 15 hingga 30 menit dengan menggunakan kapas yang telah diberi 2-3 tetes minyak esensial lavender sehingga didapatkan efek terapeutik dapat mengendurkan otot-otot yang tegang sehingga dapat membuka aliran darah yang sempit (Primadiati, 2002) Penelitian Hale (2008) mengatakan bahwa wanita yang menjalani persalinan dengan sectio caesarea menggunakan aromatherapi dengan minyak lavender dapat mengurangi rasa nyeri pada daerah insisi dan mengurangi kegelisahan. Aromaterapi dapat digunakan sebagai alternatif untuk menurunkan tingkat nyeri tanpa menimbulkan efek-efek yang merugikan seperti pada pemberian obat farmakologi. Berdasarkan studi pendahuluan tentang data persalinan yang ditangani secara sectio caesaria di RSUD Ambarawa, didapatkan rata-rata 40 ibu tiap bulan selama 1 tahun terakhir periode Januari hingga Maret yang melakukan persalinan dengan sectio caesaria tersebut. Untuk menangani nyeri persalinan tersebut, telah dilakukan beberapa metode penanganan nyeri seperti pemberian obat analgetik dan dukungan psikologis dari keluarga dekat. Dari hasil wawancara dengan 5 ibu bersalin, 3 diantaranya mengatakan bahwa ia merasa tidak nyaman dan bosan dengan konsumsi obat yang terus menerus. Ia juga mengatakan bahwa jika tidak mengkonsumsi obat ia merasa takut, cemas dan khawatir luka insisi tidak lekas sembuh. Dilema yang ini terjadi pada ibu bersalin ini mendorong peneliti untuk melakukan penelitian lebih lanjut apakah pemberian aromatherapi lavender ini akan memberikan perubahan pada tingkat nyeri ibu bersalin tersebut. Berdasarkan hal tersebut diatas maka penulis berminat melakukan penelitian tentang �Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender Pada Ibu Post Sectio Caesar Di RSUD Ambarawa� METODOLOGI PENELITIAN Desain Penelitian Penelitian ini menggunakan desain pre experiment designs dengan rancangan one group pre test-post test design, dimana tidak menggunakan kelompok kontrol sebagai pembanding, tetapi paling tidak sudah dilakukan observasi pertama (pretest) yang memungkinkan peneliti dapat menguji perubahan-perubahan yang terjadi setelah adanya eksperimen (program). Peneliti menggunakan desain eksperimen one-group pretest-posttest mempertimbangkan jumlah subyek peneliti, dan biaya. design keterbatasan dengan waktu, Populasi dan Sampel Populasi Populasi dalam penelitian ini adalah ibu post sectio caesarea di RSUD Ambarawa yang didapatkan dari hasil rata-rata tiap bulan dalam waktu satu tahun terakhir periode Januari 2013 hingga Januari 2014 dengan jumlah 40. Sampel Besar sampel dalam penelitian ini ditentukan berdasarkan estimasi (perkiraan) untuk menguji hipotesis beda rata-rata pretest dan posttest. Berdasarkan perhitungan yang telah dilakukan, diperoleh sampel sebesar 26. Jadi Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender pada Ibu Post Sectio Caesarea di RSUD Ambarawa jumlah responden yang digunakdigunakan dalam penelitian ini adalah sejumlah 26 ibu post sectio caesaria di RSUD Ambarawa barawa. digunakan dalam penelitian ini adalah sejumlah 26 ibu post sectio caesaria di RSUD Ambarawa barawa. Teknik sampling yang digunak digunakan pada penelitian ini adalah accidenaccidental sampling. Peneliti pada penelitian ini hanya akan mengambil sampel yang termasuktermasuk dalam kriteria inklusi yang antara lain: lain: 1) Ibu post sectio caesarea hari kedua yangyang bersedia menjadi subyek penelitian; 2) IIbu post sectio caesarea dengan nyeri skala ringringan sampai dengan sedang; 3) Ibu post sectiosectio caesarea yang menggunakan analgetik golong golongan sama, yaitu injeksi ketorolac; 4) Ibu bu post sectio caesarea dengan usia reproduksi sehat. duksi sehat. Adapun kriteria eksklusi pada pada penelitian ini adalah ibu post sectio caesar caesarea yang sudah pernah melakukan operasi SC/ la / laparotomi. Tempat dan Waktu Penelitian Penelitian ini dilakukan an di RSUD Ambarawa yaitu pada ibu post sectio sectio caesarea yang mengalami nyeri dengan skala ringan. Penelitian dilakukan pada tangg tanggal 21 Juli-6 Agustus 2014. Pengumpulan Data Data primer Peneliti memperoleh data a atau materi yang peneliti kumpulkan sendisendiri yang diperoleh secara langsung dari ibuibu post sectio caesarea dengan mengukur skala nyeriny ala nyerinya. Data sekunder Peneliti memperoleh data secara tidak langsung dari objek penelitian, penelitian, yaitu berasal dari sumber-sumber tertulis yangyang terdapat dalam arsip yang dimiliki bagian bagian rekam medik RSUD Ambarawa. Data sekundersekunder yang diperlukan oleh peneliti berupa berupa jumlah ibu bersalin dengan sectio caesarcaesarea di RSUD Ambarawa. Alat Ukur Alat ukur yang digunakan pada pada penelitian ini berupa lembar observasi untuk untuk mengetahui skala intensitas nyeri yang dial dialami ibu post sectio caesarea sebelum diberi perlakuan dan sesudah diberi perlakuan. Pengukuran intensitas nyeri menggunakan skala skala penilaian numerik (Numerical Rating Scale, Scale, NRS). GambarGambar 1. Skala penilaian numerik merik (Numerical Rating Scale, NRSNRS) Analisa Data Penelitian ini merupakan erupakan penelitian untuk membedakan antara satsatu variabel terikat (dependent variabel) deng dengan variabel bebas (independent variabel). D Dimana analisis data dilakukan secara komputeri puterisasi yaitu dengan program SPSS (Statistic PProduct And Service Solution). Analisa Univariat Pada penelitian ini data numerik dicari mean dan standar deviasiny inya yakni skala nyeri sebelum dan sesudah dibe diberi perlakuan berupa pemberian aromatherapi atherapi lavender melalui statistik deskriptif. Hasil sil data dibuat dalam bentuk tabel. Analisa Bivariat Analisa ini dilakukan an dengan tujuan untuk menguji variabel-variabelvariabel penelitian yaitu variabel independen dengan variabel dependen. Uji statistik t-tes dependeependent atau paired t test, digunakan untuk mengetahui adanya pengaruh intensitas nyeri sebelum dan sesudah diberikan aromaterapi lavender, yang merupakan uji statistik param ik parametrik. Uji yang digunakdigunakanan untuk menguji normalitas data maka menggunakan uji Shapiro-Wilk untuk transformtransformasi data kecil (= 50), hasil normalitas didap didapatkan hasil sebelum (0.006) dan sesudah (0.001) pemberian aromatherapi lavender masingasingm-masing kurang dari 0.05 maka data berdistribu istribusi tidak normal, sehingga uji yang dilakukandilakukan adalah uji wilcoxon. 4 Perbedaan Tingkat Nyeri SebelumSebelum dan Sesudah Pemberian Aromatherapi Lavender padapada Ibu Post Sectio Caesarea di RSUD Ambarawa HASIL PENELITIAN Analisis Univariat Nyeri Sebelum Pemberian Aromatherapi Lavender Tabel 1. Distribusi Frekuensi Berdasarkan Nyeri Sebelum Pemberian Aromatherapi Lavender Nyeri sebelum No pemberian n % aromatherapi lavender 1. Ringan 5 19.2 2. Sedang 21 80.8 Jumlah 26 100,0 Sumber: Data Primer diolah (2014) Berdasarkan Tabel 1 dapat diketahui bahwa nyeri sebelum pemberian aromatherapi lavender, sebagian besar responden mengalami nyeri sedang, yaitu ada 21 responden dengan persentase 80.8%. Nyeri Sesudah Pemberian Aromatherapi Lavender Tabel 2. Distribusi Frekuensi Berdasarkan Nyeri Sesudah Pemberian Aromatherapi Lavender Nyeri sesudah No pemberian n % aromatherapi lavender 1. Ringan 20 76.92 2. Sedang 6 23.1 Jumlah 26 100,0 Sumber : Data Primer diolah (2014) Berdasarkan Tabel 2. dapat diketahui bahwa nyeri sesudah pemberian aromatherapi lavender, sebagian besar responden mengalami nyeri ringan, yaitu ada 20 responden dengan persentase 76.92%. Analisis Bivariat Tabel 3. Hasil uji normalitas data Variabel df p value Ket. Nyeri sebelum pemberian aromatherapi lavender 26 0,006 Tidak normal Nyeri sesudah pemberian aromatherapi lavender 26 0,001 Tidak normal Hasil uji normalitas didapatkan semua p berdistribusi tidak normal, maka uji bivariat value < 0,05 sehingga dapat disimpulkan data menggunakan uji wilcoxon. Tabel 4. Test Statistics Perbedaan Nyeri Sebelum Dan Sesudah Pemberian Aromatherapi Lavender Pada Ibu Post Sectio Caesar Di RSUD Ambarawa Variabel n Mean Z p value Nyeri sebelum pemberian aromatherapi lavender 26 4.414 -4.311 0.000 Nyeri sebelum pemberian aromatherapi lavender 26 2.829 -4.311 0.000 Dari Tabel 4 dapat diketahui bahwa penurunan tingkat nyeri sebesar 1,585. Sedangkan nilai Z sebesar -4.311, jika level signifikansi 0.05 dan menggunakan uji dua sisi. Nilai Z kritis antara -1.96 dan 1.96, yang berarti berada di daerah penerimaan H1. Begitu juga diperoleh sig p-value sebesar 0,000, artinya bahwa nilai p (0.000) < 0,05 maka Ho ditolak. Hal ini berarti bahwa terdapat perbedaan nyeri sebelum dan sesudah pemberian aromatherapi lavender pada ibu post sectio caesar di RSUD Ambarawa. PEMBAHASAN Analisis Univariat Nyeri Sebelum Pemberian Aromatherapi Lavender Berdasarkan Tabel 1 gambaran tingkat nyeri sebelum diberikan aromatherapi lavender di RSUD Ambarawa dari 26 responden diperoleh data bahwa nyeri sebelum pemberian aromatherapi lavender sebagian besar responden mengalami nyeri sedang, yaitu ada 21 responden (80.8%), mengalami nyeri ringan terdapat 5 responden (19.2%), dan tidak ada Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender pada Ibu Post Sectio Caesarea di RSUD Ambarawa responden yang mengalami nyeri berat ataupun sangat berat. Pada proses operasi digunakan anastesi agar pasien tidak merasakan nyeri pada saat dibedah. Namun setelah operasi selesai dan pasien mulai sadar dan efek anestesi habis bereaksi, pasien akan merasakan nyeri pada bagian tubuh yang mengalami pembedahan. Rasa nyeri yang dirasakan post SC akan menimbulkan berbagai masalah, salah satunya masalah laktasi. Rasa nyeri tersebut akan menyebabkan pasien menunda pemberian ASI sejak awal pada bayinya, karena rasa tidak nyaman dan peningkatan tingkat nyeri setelah operasi (Batubara dkk, 2008). Penelitian mengenai nyeri sebelum diberikan aromatherapi lavender ini didapatkan hasil sebagian besar adalah responden dengan nyeri sedang yaitu sebanyak 21 responden (80,8%). Nyeri sedang adalah nyeri yang menyebar ke perut bagian bawah tetapi pasien masih dapat menunjukkan lokasi nyeri dengan tepat dan dapat mendeskripsikan, pasien dapat mengikuti perintah dengan baik dan responsif terhadap tindakan manual. Ibu post operasi SC akan merasakan nyeri, dan dampak dari nyeri akan mengakibatkan mobilisasi ibu menjadi terbatas, Activity of Daily Living (ADL) terganggu, bonding attachment (ikatan kasih sayang) dan Inisiasi Menyusui Dini (IMD) tidak terpenuhi karena adanya peningkatan tingkat nyeri apabila ibu bergerak. Hal ini mengakibatkan respon ibu terhadap bayi kurang, sehingga ASI sebagai makanan terbaik bagi bayi dan mempunyai banyak manfaat bagi bayi maupun ibunya tidak dapat diberikan secara optimal (Purwandari, 2009). Banyak ibu yang mengeluhkan rasa nyeri dibekas jahitan, keluhan ini sebetulnya wajar karena tubuh tengah mengalami luka dan penyembuhannya tidak bisa sempurna, apalagi jika luka tersebut tergolong panjang dan dalam. Pada operasi SC ada 7 lapisan perut yang harus disayat. Sementara saat proses penutupan luka, 7 lapisan tersebut dijahit satu demi satu menggunakan beberapa macam benang jahit. Rasa nyeri di daerah sayatan yang membuat sangat terganggu dan pasien merasa tidak nyaman (Walley, 2008). Hasil penelitian ini didukung oleh penelitian Khasam (2012) yang berjudul pengaruh teknik relaksasi erhadap penurunan tingkat nyeri post SC di Rs Kajen Kabupaten Pekalongan. Penelitian ini menggunakan metode penelitian dengan desain penelitian pre-experiment, pendekatan one group pretest dan posttes design without control group dengan teknik accidental sampling. Adapun populasinya yaitu pasien dengan post operasi SC. Hasil penelitian tersebut menunjukan bahwa sebagian responden mengalami nyeri sedang sebelum diberikan teknik relaksasi, dan sesudah diberikan teknik relaksasi hasil terbanyak responden mengalami nyeri ringan. Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender Berdasarkan Tabel 2 gambaran tingkat nyeri sesudah diberikan aromatherapi lavender di RSUD Ambarawa dari 26 responden diperoleh data bahwa nyeri sesudah pemberian aromatherapi lavender sebagian besar responden mengalami nyeri ringan, yaitu ada 20 responden (76.92%), mengalami nyeri sedang terdapat 6 responden (23.1%), dan tidak ada responden yang mengalami nyeri berat ataupun sangat berat. Penelitian mengenai nyeri sesudah diberikan aromatherapi lavender ini didapatkan hasil sebagian besar adalah responden dengan nyeri ringan yaitu sebanyak 20 responden (70.92%). Nyeri ringan adalah nyeri tidak mengganggu aktivitas mobilisasi atau secara obyektif pasien dapat berkomunikasi dengan baik, tindakan manual dirasa sangat membantu. Hal ini disebabkan karena responden dalam penelitian ini memiliki rasa nyaman setelah mendapatkan aromatherapi, sehingga menurunkan angka nyeri pada luka operasi. Pasien post SC yang diberikan aromatherapi lavender mengalami penurunan tingkat nyeri tetapi tidak menghilangkan nyeri tersebut karena luka dari operasi SC tersebut merupakan luka yang dibuat mulai dari lapisan perut sampai ke lapisan uterus yang penyembuhannya bertahap sehingga masih merasakan nyeri. Hal ini juga dibuktikan dengan hasil penelitian Lestari (2012) tentang perbedaan disminore primer sebelum dan sesudah diberikan aromatherapi lavender pada mahasiswi program studi DIII Kebidanan semester II Stikes Ngudi Waluyo Ungaran 2012. Hasil penelitian menunjukan bahwa sebelum diberikan aromatherapi lavender sebagian besar responden mengalami intensitas nyeri yang ringan yaitu 11 responden (64,7%) dan p value < 0.05 yang berarti ada perbedaan bermakna pada disminore primer sebelum dan Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender pada Ibu Post Sectio Caesarea di RSUD Ambarawa sesudah diberikan aromatherapi lavender pada mahasiswa DIII Kebidanan semester II Stikes Ngudi Waluyo. Hasil analisis data menggunakan Uji Wilcoxon bahwa nilai Z sebesar -4.311, jika level signifikansi 0.05 dan menggunakan uji dua sisi. Nilai Z kritis antara -1.96 dan 1.96, yang berarti berada di daerah penerimaan H1. Begitu juga diperoleh sig p-value sebesar 0,000, artinya bahwa nilai p (0.000) < 0,05 maka Ho ditolak. Hal ini berarti bahwa terdapat perbedaan nyeri sebelum dan sesudah pemberian aromatherapi lavender pada ibu post sectio caesar di RSUD Ambarawa Kabupaten Semarang. Tingkat nyeri sebelum diberikan aromatherapi lavender mengalami tingkat nyeri diantara 5-6 atau nyeri sedang, setelah pemberian aromatherapi lavender nyeri berkurang, saat pasien merasa nyaman penurunan nyeri menurun sampai ke tingkat nyeri 3 sampai 2 atau nyeri ringan. Fisiologi nyeri ini pada tahap modulasi sehingga nyeri berkuranf menjadi tingkat nyeri ringan. Pasien post SC yang telah diberikan aromatherapi lavender merasa lebih nyaman dan santai sehingga efektif untuk menurunkan tingkat nyeri. Menurut Koensoemardiyah (2009) aromaterapi digunakan untuk mempengaruhi emosi seseorang dan membantu meredakan gejala penyakit. Minyak lavender merupakan minyak esensial yang paling populer. Minyak lavender berasal dari semak yang sangat digemari di daerah mediterania. Istilah lavender berasal dari kata lavandus, yang berarti membersihkan. Hasil observasi dan tanya jawab yang dilakukan pada saat penelitian sebelum diberikan aromatherapi lavender, pasien post SC mengalami nyeri di daerah perutnya pada saat posisi berbaring, apabila pasien bergeser atau miring tingkat nyeri bertambah sehingga menggangu pasien. Aromatherapi lavender yang diberikan memberikan kenyamanan pada pasien khususnya pada saat pasien menghirup aromatherapi lavender pasien dapat mengalihkan nyeri post SC. Pengaruh aromaterapi terhadap kenyamanan dapat diukur dengan melihat berbagai indikator yang memperlihatkan kenyamanan. Indikator tersebut adalah interpretasi terhadap aromaterapi itu sendiri akan menunjukan respon emosi fight or flight, interpretasi terhadap rasa nyaman yang di dapat dari efek aromaterapi, pernyataan bahwa aromaterapi meningkatkan kinerja, peningkatan konsentrasi, pikiran lebih tenang, jiwa menjadi sejuk (Price, 2007). Respon non verbal menunjukan kenyamanan (tidak ada kerut muka, tidak ada gerakan menjauhkan diri, tidak ada pengatupan kelopak mata, tidak ada pemalingan wajah/seluruh badan) (Atkinson, R 2009). Secara teoritis aromatherapi lavender bekerja dengan mempengaruhi tidak hanya fisik tetapi juga tingkat emosi (Balkam, 2004). Kandungan lavender oil yang terdiri dari linalool, linalyl acetate, dan 1,8 -cincole dapat menurunkan, mengendorkan, dan melemaskan secara spontan ketegangan pada tikus yang mengalami spasme pada otot intestinalnya. Mekanisme massage pada tubuh dapat menstimulasi produksi endhorpin di otak, sehingga dapat memblokir transmisi stimulus nyeri. Sedangkan apabila minyak aromatherapi masuk ke rongga hidung melalui penghirupan langsung akan bekerja lebih cepat karena molekul-molekul minyak esensial mudah menguap oleh hipotalamus karena aroma tersebut diolah dan dikonversikan oleh tubuh menjadi suatu aksi dengan pelepasan subtansi neurokimia berupa zat endorphin dan serotinin sehingga berpengaruh langsung pada organ penciuman dan dopersepsikan oleh otak untuk memberikan reaksi yang membuat perubahan fisiologis pada tubuh., pikiran, jiwa, dan menghasilkan efek menenangkan pada tubuh (Nurachman, 2004). Hasil penelitian ini didukung oleh hasil penelitian Restiana (2013), yang berjudul efek lilin aromatherapi lavender terhadap perubahan intensitas nyeri persalinan normal kala 1 fase aktif pada primigravida di wilayah kerja Puskesmas Bergas Kabupaten Semarang. Penelitian ini menggunakan metode penelitian quasy experimental design dengan desain penelitian pretest-posttest time control design, dengan teknik accidental sampling. Adapun populasinya yaitu ibu bersalin kala 1 fase aktif pada primigravida. Hasil penelitian menunjukkan bahwa ada pengaruh yang signifikan lilin aromatherapi lavender terhadap perubahan intensitas nyeri persalinan kala I fase aktif pada primigravida di wilayah kerja Puskesmas Bergas Kabupaten Semarang (pvalue = 0,000 < a (0,05). Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender pada Ibu Post Sectio Caesarea di RSUD Ambarawa Keterbatasan Penelitian Dalam penelitian inipun mempunyai keterbatasan, yaitu peneliti tidak dapat mengendalikan faktor-faktor lain yang dapat mempengaruhi nyeri pada ibu post SC seperti faktor usia, kebudayaan, perhatian, keletihan, pengalaman sebelumnya, dan dukungan keluarga dan sosial. KESIMPULAN Sebagian besar responden mengalami nyeri sedang sebelum pemberian aromatherapi lavender yaitu 21 responden atau 80.77%. Sebagian besar responden mengalami nyeri ringan sesudah pemberian aromatherapi lavender yaitu 20 orang atau 76.92%. Penurunan tingkat nyeri sebelum dan sesudah diberikan aromatherapi lavender adalah sebesar 1.585. Terdapat perbedaan nyeri sebelum dan sesudah pemberian aromatherapi lavender pada ibu post sectio caesar di RSUD Ambarawa yaitu dengan p value 0.000 < a (0.05). SARAN Hasil penelitian diharapkan dapat dipergunakan sebagai sumber pengetahuan peneliti mengenai manfaat aromaterapi (aroma lavender) terhadap perubahan tingkat nyeri ibu pada ibu post sectio caesaria. Hasil penelitian diharapkan dapat dipergunakan sebagai sumber pertimbangan bagi tempat penelitian untuk menerapkan metoda aromaterapi (aroma lavender) dalam mengatasi perubahan tingkat nyeri ibu pada ibu post sectio caesaria. Hasil penelitian diharapkan dapat dipergunakan sebagai salah satu metode menurunkan nyeri pada saat responden merasakan nyeri post SC. DAFTAR PUSTAKA [1] Anggorowati, dkk. Efektifitas pemberian intervensi spiritual �spirit ibu� terhadap nyeri post sectio caesarean (SC) pada Rs Sultan Agung Dan Rs Roemani Semarang. Journal Media Ners, Vol.8 No.2, Juli 2007. [2] Bambang Prasetyo. (2006). Metode penelitian kuantitatif. Jakarta : Raja grafindo persada. [3] Batbual, B (2010).Hypnosis Hypnobirthing .Yogyakarta.Gosyen Publishing [4] Batubara, dkk. (2008). Hubungan pengetahuan, nyeri pembedahan sectio caesaria dan bentuk puting dengan pemberiann air susu ibu pertama kali pada ibu post partum. Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing), Volume 3 No.2 Juli 2008 54. [5] Bobak. (2004). Buku ajar keperawatan maternitas edisi 4. Jakarta : EGC. [6] Cunningham. (2006). Obstetri Williams. Jakarta: EGC. [7] Dahlan, Sopiyudin (2009). Besar Sampel dan Cara Pengambilan Sampel. Jakarta : Salemba Medika [8] Jacob, T. (2004). Etika Penelitian Ilmiah. Warta Penelitian Universitas Gadjah Mada (Edisi Khusus), 60-63. [9] Koensoemardiyah. (2009). A-Z Aromaterapi untuk Kesehatan, Kebugaran, dan Kecantikan. Yogyakarta: Lily Publisher. [10] Laila. (2011). Buku Pintar Menstruasi. Yogyakarta: Bukubiru [11] Mochtar. (2008). Sinopsis Obstetri. Jakarta: EGC. [12] Notoadmodjo, S (2010). Metodologi Penelitian Kesehatan. Jakarta: Rineka Cipta [13] Nursalam, (2010). Konsep dan Penerapan Metodologi Penelitian Ilmu keperawatan. Jakarta: Salemba Medika [14] Ogan, M. (2005). A pilot study evaluating mindfulness based stress reduction and massage for the management of chronic pain. USA [15] Padilla. (2008). Risk Factors in Cesarean Section. Ginecol Obstet Mex Article in Spanish. [16] Potter & Perry. (2005). Buku ajar fundamental keperawatan, edisi ke-4. Penerbit buku kedokteran. Jakarta: EGC. Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender pada Ibu Post Sectio Caesarea di RSUD Ambarawa [17] Potter & Perry. (2006). Buku ajar fundamental keperawatan, konsep, proses, dan praktik edisi 4. Jakarta : EGC. [18] Saryono. (2008) Metodologi penelitian kesehatan. Yogyakarta: Mitra cendekia. [19] Simkin. (2008). Paduan Lengkap Kehamilan, Melahirkan, dan Bayi. Jakarta: Arcan. [20] Smeltzer. (2002). Buku ajar keperawatan medikal bedah Brunner and Suddarth. (8 th edition). Jakarta: EGC. [21] Sugiyono. (2007). Metode penelitian kuantitatif kualitatif dan R&D. Bandung: Alfabeta. [22] Sulistyowati. (2009). Efektifitas Terapi Aroma Lavender Terhadap Tingkat Nyeri dan Kecemasan Persalinan Primipara Kala I di Rumah Sakit dan Klinik Bersalin Purwokerto. [23] Whalley. (2008). Panduan lengkap kehamilan, melahirkan, dan bayi, edisi revisi. Jakarta: Arcan. [24] Yuliatun. (2008). Penangangan nyeri persalinan dengan metode nonfarmakologi. Malang: Bayumedia Publishing. Perbedaan Tingkat Nyeri Sebelum dan Sesudah Pemberian Aromatherapi Lavender pada Ibu Post Sectio Caesarea di RSUD Ambarawa EFEKTIVITAS AROMATERAPI LAVENDER DAN AROMATERAPI LEMON TERHADAP INTENSITAS NYERI POST SECTIO CAESAREA (SC) DI RUMAH SAKIT BUDI RAHAYU KOTA MAGELANG Ina Rahmawati �, Dr. Heni Setyowati E. R., S. Kp., M. Kes�, Ns. Rohmayanti, M. Kep� Abstrak Latar belakang: Nyeri merupakan suatu keadaan yang tidak nyaman yang sering dirasakan oleh pasien post sectio caesarea. Aromaterapi dapat digunakan untuk mengatasi nyeri post sectio caesarea. Tujuan:Penelitian ini bertujuan untuk mengetahui efektivitas antara aromaterapi lavender dan aromaterapi lemon di Rumah Sakit Budi Rahayu Kota Magelang. Metode:penelitian ini menggunakan metodequasy experimentdengan rencangan two group pre-test and post- test designdengan sampel 56 responden, 28 responden kelompok aromaterapi lavender dan 28 responden kelompok aromaterapi lemon. Teknik pengambilan sampel menggunakan consecutive samplingInstrumen yang digunakan adalah numeric rating scale (NRS). Data diolah dengan uji Wilcoxon dan uji Mann Whitney.Hasil: hasil penelitian ini menunjukkan bahwa aromaterapi lavender dan aromaterapi lemon efektif dalam menurunkan skala nyeri post sectio caesarea dengan p value 0,009 (p < 0,05). Kesimpulan: Aromaterapi levender dan aromaterapi lemon efektif dalam menurunkan skala nyeri post sectio caesarea,tetapi aromaterapi lemon lebih efektif dalam mengatasi nyeri post sectio caesarea dengan nilai rata-rata sebesar 4 lebih besar dibandingkan rata-rata aromaterapi lavender yaitu 2,15.Saran: Rekomendasi penelitian ini adalah supaya menggunakan aromaterapi lavender dan aromaterapi lemon sebagai intervensi alternatif yang digunakan untuk menurunkan nyeri post sectio caesarea. Kata Kunci : Aromaterapi Lavender, Aromaterapi Lemon, Nyeri Post Sectio Caesarea 1. PENDAHULUAN caesarea 24,6%. Selain itu angka Section caesarea suatu tindakan kejadian sectio caesarea di Australia pembedahan atau suatu persalinan pada tahun 1998 sekitar 21% dan buatan yang tujuannya untuk pada tahun2007 sekitar 31%. Di mengeluarkan bayi dengan cara Indonesia angka kejadian sectio membuka dinding perut dan rahim caesarea mengalami peningkatan ibu dengan sayatan rahim ibu dalam pada tahun 2000-2006 sebesar keadaan utuh serta berat janin diatas 48,85% dan pada tahun 2011-2013 500 gram (Lia, 2010). sebesar 49,6% (Kulas, 2008). Dari tahun ke tahun angka Masalah yang muncul pada kejadian sectio caesarea terus tindakan setelah operasi sectio meningkat. Angka persalinan melalui caesarea akibat insisi oleh robekan sectio caesarea di Amerika Serikat jaringan dinding perut dan dinding telah meningkat empat kali lipat, dari uterus dapat menyebabkan terjadinya 5,5 per 100 kelahiran pada tahun perubahan kontinuitas sehingga ibu 1970 menjadi 22,7 per 100 kelahiran merasa nyeri karena adanya pada tahun 1985.Di Inggris, pada pembedahan ( Asamoah, 2011). tahun 2008-2009 angka sectio Penanganan yang sering digunakan untuk menurunkan nyeri post sectio caesarea berupa penanganan farmakologi dan non farmakologi. Salah satu terapi non farmakologi yang dapat digunakan yaitu aromaterapi. (Anggorowati, 2007). Efek aromaterapi positif karena aroma yang segar dan harum merangsang sensori dan akhirnya mempengaruhi organ lainnya sehingga dapat menimbulkan efek yang kuat terhadap emosi. Aromaterapi ditangkap oleh reseptor dihidung, kemudian memberikan informasi lebih jauh karena di otak yang mengontrol emosi dan memori serta memberikan informasi ke hipotalamus yang merupakan pengatur sistem internal tubuh, sistem seksualitas, suhu tubuh, dan reaksi terhadap stres (Hale, 2008). Mekanisme kerja aromaterapi dalam tubuh manusia berlangsung melalui dua sistem fisiologis, yaitu sirkulasi tubuh dan sistem penciuman. Wewangian dapat mempengaruhi kondisi psikis, daya ingat, dan emosi seseorang. Aromaterapi lemon merupakan jenis aromaterapi yang dapat digunakan untuk mengatasi nyeri dan cemas (Wong, 2010). Jenis aromaterapi diantaranya adalah aromaterapi lavender dan buah lemon. Aromaterapi lavender dapat memberikan ketenangan, keseimbangan, rasa nyaman, rasa keterbukaa, dan keyakinan. Disamping itu juga dapat mengurangi rasa tertekan, stres, rasa sakit, emosi yang tidak seimbang, histeria, rasa frustasi dan kepanikan. Lavender dapat bermanfaat untuk mengurangi rasa nyeri, dan dapat memberikan relaksasi (Hutasoit, 2002). Aromaterapi lemon merupakan jenis aroma terapi yang dapat digunakan untuk mengatasi nyeri dan cemas. Zat yang terkandung dalam lemon salah satunya adalah linalool yang berguna untuk menstabilkan sistem saraf sehingga dapat menimbulkan efek tenang bagi siapapun yang menghirupnya (Wong, 2010). Aromaterapi lavender dan buah lemon dapat digunakan untuk mengatasi nyeri post sectio caesarea. Didukung oleh penelitian dari Wening Dwijayanti, Sri Sumarni, dan Ida Ariyanti dengan hasil penurunan nyeri rata-rata antara sebelum dan sesudah pemberian aromaterapi lavender secara inhalasi adalah sebesar 1,13. Hasi penelitian didapatkan p value 0,001(<0,05) dan hasil t-hitung sebesar 9,000 (>ttabel= 2,042) yang berarti ada perbedaan yang signifikan antara sebelum dan sesudah pemberian aromaterapi lavender secara inhalasi dan juga penelitian lain yang mendukung ialah penelitiannya Fadhla Purwandari, Siti Rahmalia, dan Febrian Sabrian dengan hasil yang melalui uji statistik diperoleh nilai p (0,000) < a (0,05), maka dapat disimpulkan bahwa terdapat perbedaan yang signifikan antara rata-rata skala nyeri sebelum dengan rata-rata skala sesudah menghirup aroma lemon pada kelompok eksperimen. Namun belum diketahui perbedaan efektivitasnya, sehingga peneliti tertarik meneliti perbedaan efektivitas aromaterapi lavender dan aromaterapi lemon terhadap intensitas nyeri post sectio caesarea. 2. METODOLOGI PENELITIAN Penelitian ini merupakan penelitian quasi eksperiment dengan desain rancangan two group pre test and post test design. Instrumen yang digunakan dalam penelitian ini berupa data karakteristik dan kuesioner. Pada data karakteristik data berupa lembaran demografi yang berisi data karakteristik responden yang meliputi usia, pendidikan terakhir, dan pekerjaan. Pada kuesioner skala numeric Rating Scale adalah suatu garis lurus yang digunakan untuk mengukur intensitas nyeri dan pendeskripsi verbal pada setiap ujungnya dengan rentang nyeri 0-10 sesuai dengan tingkatnya yang berarti 0 adalah tidak nyeri, 1-3 adalah nyeri ringan, 4-6 adalah nyeri sedang dan 7-10 adalah nyeri yang tidak terkontrol. Adapun populasi target dari penelitian ini adalah ibu bersalin dengan cara sectio caesarea. Populasi terjangkau dalam penelitian ini yaitu ibu bersalin dengan sectio caesarea.Adapun populasi target dari penelitian ini adalah ibu bersalin dengan cara sectio caesarea. Populasi terjangkau dalam penelitian ini yaitu ibu bersalin dengan sectio caesarea. pemilihan sampel dengan cara non-probability sampling, Dengan tanik consecutive sampling. Sedangkan penentuan sampel kelompok aromaterapi lavender dan kelompok aromaterapi lemon menggunakan undian. Analisa data yang digunakan menggunakan uji Wilcoxon dan Mann-Whitney. 3. HASIL DAN PEMBAHASAN Berikut penjelasan karakteristik responden diantaranya umur, pendidikan, dan pekerjaan Tabel 1 Berdasarkan karakteristik Aromaterapi Aromaterapi variabel Lavender (n=28) Lemon (n=28) P Mean Sd Jumlah Mean Sd Jumlah value % % Usia 21,36 1,890 21,25 2,238 2,238 0,059 18-25 Tingkat pendidikan SD 25,0 28,6 17,9 42.9 0,310 SMP 35,7 28,6 SMA 10,7 10,7 Perguruan Tinggi Pekerjaan 0,261 IRT 64,3 64,3 PNS 28,6 10,7 KARYAWAN 7,1 25,0 Tabel 1 menunjukkan bahwa hasil uji varian yang sama sehingga dapat homogenitas pada kedua kelompok disimpulkan bahwa kelompok pada masing-masing karakteristik intervensi aromaterapi lavender dan menunjukkan P value >0.05 yang kelompok aromaterapi lemon artinya kedua kelompok memiliki memiliki karakteristik yang sama. Tabel 2 Uji Normalitas Nyeri Post Sectio Caesarea Sebelum dan Setelah Dilakukan Tindakan Pada Kelompok Aromaterapi Lavender Shapiro-Wilk Statistik df sig AT lavender ke 1 ,605 28 ,000 Pre test AT lavender ke 2 AT Lavender ke 3 ,800 ,774 28 28 ,000 ,000 AT Lavender ke 4 ,867 28 ,002 AT Lavender ke 1 ,926 28 ,049 Post test AT Lavender ke 2 AT Lavender ke 3 ,786 ,904 28 28 ,000 ,014 AT Lavender ke 4 ,861 28 ,002 Tabel 2 menunjukkan bahwa variaabel nyeri responden sebelum diberikan aromaterapi pada kelompok aromaterapi lavender dengan menggunakan uji Shapirow- Wilk pada kelompok aromaterapi lavender ke 1 didapatkan hasil P=0, 000, pada kelompok aromaterapi lavender ke 2 didapatkan hasil P=0,000, pada kelompok aromaterapi lavender ke 3 didapatkan hasil P=0, 000, pada kelompok aromaterapi lavender ke 4 didapatkan hasil P=0,002. Dan setelah diberikan aromaterapi lavender, pada kelompok aromaterapi lavender ke 1 didapatkan hasil P=0,049, pada kelompok aromaterapi lavender ke 2 didapatkan hasil P=0,000, pada kelompok aromaterapi lavender ke 3 kelompok aromaterapi lavender ke 4 didapatkan hasil P=0,014, pada didapatkan hasil P=0,002 Tabel 3 Uji Normalitas Post Sectio Caesarea Setelah Dilakukan Tindakan Pada Kelompok Aromaterapi Lemon Shapiro-Wilk Statistik df sig AT Lemon ke 1 ,842 28 ,001 Pre test AT Lemon ke 2 ,734 28 ,000 AT Lemonke 3 ,833 28 ,000 AT Lemonke 4 ,879 28 ,002 AT Lemon ke 1 ,915 28 ,026 Post test AT Lemon ke 2 ,871 28 ,003 AT Lemonke 3 ,920 28 ,034 AT Lemon ke 4 ,858 28 ,001 Tabel 3 menunjukkan bahwa variaabel nyeri responden sebelum diberikan aromaterapi, pada kelompok aromaterapi lemon dengan menggunakan uji Shapirow-Wilk pada kelompok aromaterapi lemon ke 1 didapatkan hasil P=0, 001, pada kelompok aromaterapi lemon ke 2 didapatkan hasil P=0,000, pada kelompok aromaterapi lemon ke 3 didapatkan hasil P=0, 000, pada kelompok aromaterapi lemon ke 4 didapatkan hasil P=0,002. Dan setelah diberikan aromaterapi lemon pada kelompok aromaterapi lemon ke 1 didapatkan hasil P=0,026, pada kelompok aromaterapi lemon ke 2 didapatkan hasil P=0,003, pada kelompok aromaterapi lemon ke 3 didapatkan hasil P=0,034, pada kelompok aromaterapi lemon ke 4 didapatkan hasil P=0,001 Tabel 4 Perbedaan Skor Nyeri Post Sectio caesareaSebelum dan Setelah Dilakukan Terapi Aromaterapi Lavender pada Tindakan 1, 2, 3 dan 4 Variabel Mean Meandefferent sd P value Nyeri post SC Intervensi 1 1,43 ,000 Sebelum 8,14 0,448 sesudah 6,71 1,084 Nyeri post SC Intervensi 2 1,75 ,000 Sebelum 7,50 0,638 Sesudah 5.75 1,295 Nyeri post SC Intervensi 3 2,61 ,000 Sebelum 6,68 0,723 Sesudah 3,89 1,257 Nyeri post SC Intervensi 4 2,15 ,000 Sebelum 5,54 1,105 Sesudah 3,39 1,474 *Uji Wilcoxon Tabel 4 menunjukan bahwa terdapat aromaterapi lavender pada tindakan penurunan signifikan skor nyeri ke 4 sebesar 5,54 dan setelah sebelum dan setelah diberikan diberikan aromaterapi lavender pada aromaterapi lavender pada kelompok tindakan ke 4 sebesar 3,39 dengan aromaterapi lavender dengan hasil p=0,000 rata-rata nyeri sebelum diberikan Untuk Memperjelas perbedaan skor nyeri post sectio caesarea sebelum dan sesudah pemberian aromaterapi lavender peneliti gambarkan dengan histrogram. Histrogram 1 Perbedaan Skor Nyeri Post Sectio Caesarea Sebelum Dan Sesudah Dilakukan Aromaterapi Lavender 0 1 2 3 4 5 6 7 8 9 Tindakan ke1 tindakan ke 2 Tindakan ke 3 Tindakan ke 4 pre post Tabel 4.5 Perbedaan Skor Nyeri Post Sectio caesarea Sebelum dan Setelah Dilakukan Terapi Aromaterapi Lemon pada Tindakan 1, 2, 3 dan 4 Variabel mean Mean sd P value defferent Nyeri post SC Intervensi 1 2,43 ,000 Sebelum 7,93 0,858 Sesudah 5,50 1,427 Nyeri post SC Intervensi 2 post SC Intervensi 2 3,14 ,000 Sebelum 7,46 0,637 Sesudah 4,32 1,249 Nyeri post SC Intervensi 3 3,04 ,000 Sebelum 6,18 0,723 Sesudah 3,14 1,380 Nyeri post SC Intervensi 4 4 ,000 Sebelum 5,39 0,875 Sesudah 1,39 1.066 *Uji Wilcoxon Tabel 5 menunjukan bahwa terdapat rata nyeri sebelum diberikan penurunan signifikan skor nyeri aromaterapi lemon pada tindakan ke sebelum dan setelah diberikan 4 sebesar 5,39 dan setelah diberikan aromaterapi lemon pada kelompok aromaterapi lavender pada tindakan aromaterapi lemon dengan hasil rata-ke 4 sebesar 1,39 dengan p=0,000 Untuk Memperjelas perbedaan skor nyeri post sectio caesarea sebelum dan sesudah pemberian aromaterapi lavender peneliti gambarkan dengan histrogram. Histrogram 4.2 Perbedaan Skor Intensitas Nyeri Post Sectio Caesarea Sebelum Dan Sesudah Dilakukan Aromaterapi Lemon 0 1 2 3 4 5 6 7 8 9 Tindakan ke 1 Tindakan ke 2 Tindakan ke 3 Tindakan ke 4 pre post Tabel 4.6 Perbedaan penurunan Skor Nyeri Post Sectio Caesarea sebelum dan setelah diberikan tindakan Aromaterapi Lavender dan Aromaterapi Lemon Pada Tindakan 1, 2, 3 dan 4 Tindakan Aromaterapi Aromaterapi Mean P value lavender lemon Different Tindakan ke 1 Sebelum Sesudah Tindakan ke 2 Sebelum Sesudah Tindakan ke 3 Sebelum Sesudah Tindakan ke 4 Sebelum Sesudah Sebelum Sesudah Tindakan ke 2 Sebelum Sesudah Tindakan ke 3 Sebelum Sesudah Tindakan ke 4 Sebelum Sesudah 8,14 6,71 7,50 5,75 6,68 3,89 5,54 3,39 7,93 5,50 7,46 4,32 6,18 3,14 5,39 1,39 0,257 1 0,028 1,39 0,019 0,25 0,009 1,85 *Uji Mann Whitney Tabel 6 menunjukan bahwa terdapat perbedaan yang signifikan terdapat rata-rata nyeri post sectio caesarea diantara kedua kelompok pada tindakan ke 4 didapatkan hasil p= 0,009. Hasil penelitian ini menunjukkan bahwa Aromaterapi lemon lebih efektif dalam mengatasi nyeri post sectio caesarea dengan nilai rata-rata sebesar 4 lebih besar dibandingkan rata-rata aromaterapi lavender yang sebesar 2,15. Hasil penelitian ini juga didukung oleh penelitian yang sebelumnya yang dilakukan oleh Isa Khasani (2013) tentang pengaruhpemberian aromaterapi terhadap nyeri pada pasien post operasi sectio caesrea di RSUD kajen kabupaten pekalongan dengan p value sebesar 0,001 (P < 0,05). Hasil penelitian lainnya yaitu dilakukan oleh Nurfitriani (2016) menyatakan bahwa ada pengaruh pemberian aromaterapi lemon secara inhalasi terhadap derajat disminorea primer dengan p value 0,000 (P < 0,05). Pada penelitian Jaya (2013) menyatakan bahwa ada pengaruh pemberian aromaterapi terhadap tingkat nyeri pada ibu bersalin primipara kala 1 fase aktif di RSUD kabupaten kediri dengan p value 0,002 (P < 0,05. Aromaterapi lemon efektif untuk menurunkan nyeri post sectio cesarea karena aromaterapi lemon mengandung minyak atsiri yang bermanfaat sebagai anti stres. Minyak atsiri lemon mampu menenangkan, sehingga dapat membantu dalam menghilangkan kelelahan mental, pusing, gelisah, gugup, ketegangan saraf dan menurunkan nyeri. Minyak atsiri lemon memiliki kemampuan untuk menyegarkan pikiran, yaitu dengan menciptakan pikiran dalam bingkai positif dan menghapus emosi negatif. Menghirup minyak atsiri lemon dapat membantu dalam meningkatkan konsentrasi dan kewaspadaan (Anonim, 2013). Banyaknya manfaat tersebut akan terbuang bila minyak lemon mudah menguap dan mudah habis, untuk itu diperlukan cara untuk melindungi bahan aktif dalam minyak lemon agar tidak cepat menguap. 4. KESIMPULAN DAN SARAN KESIMPULAN 1. Intensitas nyeri post sectio caesarea sebelum diberikan aromaterapi lavender yaitu 5,54 2. Intensitas nyeri post sectio caesarea sesudah diberikan aromaterapi lavender yaitu 3,39 3. Terdapat perbedaan penurunan intensitas nyeri post sectio caesarea sebelum dansesudah diberikan aromaterapi lavender yaitu 2,15 4. Intensitas nyeri post sectio caesarea sebelum diberikan aromaterapi lemon yaitu 5,39 5. Intensitas nyeri post sectio caesarea sesudah diberikan aromaterapi lemon yaitu 1,39 6. Terdapat perbedaan penurunan intensitas nyeri post sectio caesarea sebelum dan sesudah diberikan aromaterapi lemon yaitu 4 7. Terdapat perbedaan intensitas nyeri post sectio caesarea setelah pemberian aromaterapi lavender dan lemon yaitu 1,85. SARAN 1. Bagi Ibu Post Sectio Caesarea dan Masyarakat Dengan penelitian ini diharapkan ibu post sectio caesarea dan masyarakat dapat menjadikan aromaterapi sebagai salah satu pengobatan alternatif bagi masyarakat yang mengalami nyeri post sectio caesrea agar menggunakan aromaterapi lavender dan aromaterapi lemon sebagai terapi non farmakologi dalam mengatasi nyeri. 2. Pelayanan Keperawatan Dengan penelitian ini diharapkan pelayanan keperawatan bukan hanya memberikan terapi farmakologis dalam mengatasi nyeri post sectio caesarea pada ibu post sectio caesarea, namun dapat memberikan terapi komplementer yang berupa aromaterapi laveder dan aromaterapi lemon untuk menangani nyeri post sectio caesarea dalam melaksanakan perannya sesuai undang-undang keperawatan. 3. Penelitian Selanjutnya Dengan penelitian ini diharapkan penelitian selanjutnya dapat menjadikan penelitian ini sebagai referensi bagipeneliti lain untuk melakukan penelitian dengan intervensi yang berbeda. selain itu penelitian selanjutnya diharapkan dapat meneliti jenis-jenis aromaterapi yang lainnya, dalam mengatasi nyeri post sectio caesarea. DAFTAR PUSTAKA 1. Alexander, M. (1994). Biodegradation and Bioremediation. Academic Press, New York. 2. Anggorowati. (2007). 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AROMATERAPI LAVENDER SEBAGAI MEDIA RELAKSASI IGA Prima Dewi AP Bagian Farmasi Fakultas Kedokteran Universitas Udayana ABSTRAK Aromaterapi adalah salah satu teknik pengobatan atau perawatan menggunakan baubauan yang menggunakan minyak esensial aromaterapi. Proses ekstraksi (penyulingan) minyak esensial ini secara umum dapat dilakukan dengan tiga cara, yaitu penyulingan dengan dengan air (direbus), penyulingan dengan air dan uap (dikukus), dan penyulingan dengan uap (diuapkan). Salah satu aroma yang paling digemari adalah lavender. Kandungan utama dari bunga lavender adalah linalyl asetat dan linalool (C10H18O). Linalool adalah kandungan aktif utama yang berperan pada efek anti cemas (relaksasi) pada lavender. Menurut hasil dari beberapa jurnal penelitian, didapatkan kesimpulan bahwa minyak esensial dari bunga lavender dapat memberikan manfaat relaksasi (carminative), sedatif, mengurangi tingkat kecemasan, dan mampu memperbaiki mood seseorang Kata kunci: aromaterapi, lavender, linalool, relaksasi LAVENDER AROMATERAPHY AS A RELAXANT ABSTRACT Aromatherapy is a kind of treatment that used aroma with aromatherapy essential oil. Extraction process from essential oil generally doing in three methods, there are distilling with water (boiled), distilling with water and steam, and distilling with steam. One of the most favorite aroma is lavender. The main content from lavender is linalyl acetate and linalool (C10H18O). Linalool is main active contents in lavender which can use for anti-anxiety (relaxation). Based on some research, the conclusion indicates that essential oil from lavender can give relaxation (carminative), sedative, reduce anxiety level and increasing mood. Keywords: aromatherapy, lavender, linalool, relaxation PENDAHULUAN Tuntutan hidup yang semakin besar dan keinginan orang untuk mendapatkan hidup yang lebih baik mendorong setiap orang untuk bekerja lebih keras sehingga menimbulkan rasa lelah, baik itu dalam pikiran maupun fisik. Saat ini berwisata juga bertujuan untuk mendapatkan ketenangan yang dapat dilakukan dengan wisata spa. Bali sebagai daerah tujuan wisata yang sangat diminati oleh para wisatawan juga menyediakan fasilitas wisata spa tersebut. Wisata spa saat ini menjadi salah satu trend terbaru bagi wisatawan yang berlibur di Bali, banyak wisatawan yang memang sengaja datang ke Bali dengan tujuan melakukan wisata spa. Bahkan salah satu spa terbaik di dunia terdapat di Bali. Salah satu aroma untuk aromaterapi yang paling digemari adalah lavender. Berasal dari bunga levender yang berbentuk kecil dan berwarna ungu. Bunga lavender dapat digosokkan ke kulit, selain memberikan aroma wangi, lavender juga dapat menghindarkan diri dari gigitan nyamuk4. Aromaterapi menggunakan minyak lavender dipercaya dapat memberikan efek relaksasi bagi saraf dan otot-otot yang tegang (carminative) setelah lelah beraktivitas5. Bunga lavender juga memiliki efek 5,6,7 memberikan rasa kantuk (sedatif). Melalui tulisan ini, diharapkan dapat memberikan tambahan wawasan atau ilmu pengetahuan bagi pembaca tentang gambaran umum dan zat yang terkandung dalam bunga lavender, proses pengolahan minyak lavender, serta manfaat relaksasi bunga lavender. BUNGA LAVENDER Bunga lavender memiliki 25-30 spesies, beberapa diantaranya adalah Lavandula angustifolia, lavandula lattifolia, lavandula stoechas (Fam. Lamiaceae)8. Penampakan bunga ini adalah berbentuk kecil, berwarna ungu kebiruan, dan tinggi tanaman mencapai 72 cm. Asal tumbuhan ini adalah dari wilayah selatan Laut Tengah sampai Afrika tropis dan ke timur sampai India. Lavender termasuk tumbuhan menahun, tumbuhan dari jenis rumput-rumputan, semak pendek, dan semak kecil. Tanaman ini juga menyebar di Kepulauan Kanari, Afrika Utara dan Timur, Eropa selatan dan Mediterania, Arabia, dan India. Karena telah ditanam dan dikembangkan di tamantaman di seluruh dunia, tumbuhan ini sering ditemukan tumbuh liar di daerah di luar daerah asalnya9 (Gambar 1). Tanaman ini tumbuh baik pada daerah dataran tinggi, dengan ketinggian berkisar antara 600-1.350 m di atas permukaan laut. Untuk mengembangbiakkan tanaman ini tidaklah sulit, dimana menggunakan biji dari tanaman lavender yang sudah tua dan disemaikan. Bila sudah tumbuh, dapat dipindahkan ke polybag. Bila tinggi tanaman telah mencapai 15-20 cm, dapat dipindahkan ke dalam pot atau bisa ditanam di halaman 4,10 rumah. Nama lavender berasal dari bahasa Latin �lavera� yang berarti menyegarkan dan orang-orang Roma telah memakainya sebagai parfum dan minyak mandi sejak zaman dahulu9. Bunga lavender dapat digosokkan ke kulit, selain memberikan aroma wangi, lavender juga dapat menghindarkan diri dari gigitan nyamuk. Bunga lavender kering dapat diolah menjadi teh yang dapat kita konsumsi. Manfaat lain bunga lavender adalah dapat dijadikan minyak esensial yang sering dipakai sebagai aromaterapi karena dapat memberikan manfaat relaksasi dan memiliki efek sedasi yang sangat membantu pada orang yang mengalami insomnia. Minyak esensial dari lavender biasanya diencerkan terlebih dahulu dengan minyak lain dari tumbuh-tumbuhan (carrier oil) seperti sweet almond oil, apricot oil, dan grapeseed oil agar dapat diaplikasikan pada tubuh untuk massage aromaterapi1. Zat yang Terkandung pada Minyak Lavender Minyak lavender memiliki banyak potensi karena terdiri atas beberapa kandungan. Menurut penelitian, dalam 100 gram bunga lavender tersusun atas beberapa kandungan, seperti: minyak esensial (1-3%), alpha-pinene (0,22%), camphene (0,06%), betamyrcene (5,33%), p-cymene (0,3%), limonene (1,06%), cineol (0,51%), linalool (26,12%), borneol (1,21%), terpinen-4-ol (4,64%), linalyl acetate (26,32%), geranyl acetate (2,14%), dan caryophyllene (7,55%). Berdasarkan data di atas, dapat disimpulkan bahwa kandungan utama dari bunga lavender adalah linalyl asetat dan linalool7 (C10H18O). Diteliti efek dari tiap kandungan bunga lavender untuk mencari tahu zat mana yang memiliki efek anti-anxiety (efek anti cemas/relaksasi) menggunakan Geller conflict test dan Vogel conflict test. Cineol, terpinen-4-ol, alpha-pinene, dan betamyrcene tidak menghasilkan efek anti cemas yang signifikan pada tes Geller. Linalyl asetat sebagai salah satu kandungan utama pada lavender tidak menghasilkan efek anti cemas yang signifikan pada kedua tes. Borneol dan camphene memberikan efek anti cemas yang signifikan pada tes Geller, tapi tidak signifikan pada tes Vogel. Linalool, yang juga merupakan kandungan utama pada lavender, memberikan hasil yang signifikan pada kedua tes. Dapat dikatakan, linalool adalah kandungan aktif utama yang berperan pada efek anti cemas (relaksasi) pada lavender7. Proses Pembuatan Minyak Lavender Kandungan minyak esensial dari tumbuh-tumbuhan, seperti pada batang, daun, akar, buah, dan bunga dapat diisolasi atau dipisahkan dengan berbagai cara, salah satunya adalah dengan penyulingan (distilation). Penyulingan merupakan proses yang sangat menentukan untuk mendapatkan minyak esensial dari suatu tanaman. Terdapat beberapa cara penyulingan yang dapat dilakukan untuk menghasilkan minyak esensial dan cara-cara tersebut tergantung pada volume serta ketersediaan alat-alat pendukung di lokasi penyulingan. Alat penyulingan minyak sebaiknya terbuat dari bahan stainless steel. Jika proses penyulingan dibuat dari bahan lain (non-stainless steel), minyak yang dihasilkan akan tampak keruh3. Pertama yang harus kita lakukan sebelum penyulingan adalah memotong bunga lavender menjadi bagian yang lebih kecil. Hal ini bertujuan agar kelenjar minyak pada bunga dapat terbuka sebanyak mungkin sehingga memaksimalkan produksi minyak esensial3. Tahap selanjutnya adalah mengeringkan bunga lavender pada tempat yang teduh atau ruang tertutup selama kurang lebih dua hari. Hal ini bertujuan untuk mempercepat proses penyulingan dan mendapatkan hasil yang lebih baik. Jangan langsung mengeringkan di bawah sinar matahari karena dapat mengakibatkan sebagian minyak dari bunga ikut menguap. Selain itu, pengeringan yang terlalu cepat dapat mengakibatkan bunga menjadi rapuh dan sulit untuk disuling. Bila dua tahap di atas telah dikerjakan, bunga lavender siap untuk disuling menjadi minyak esensial3. Menurut Tuhana Taufik (2007), teknik penyulingan minyak esensial dapat dilakukan dengan tiga cara, yaitu penyulingan dengan air (direbus), penyulingan dengan air dan uap (dikukus), dan penyulingan dengan uap (diuapkan). 1. Penyulingan dengan air (direbus) Teknik penyulingan ini adalah teknik yang paling pertama dilakukan dan masih digunakan sampai saat ini oleh petani tradisional. Dalam teknik ini, ketel penyulingan diisi air sampai sampai volumenya hampir separuh dari volume ketel, lalu dipanaskan. Sebelum air mendidih, bahan baku dimasukkan dalam ketel penyulingan. Dengan demikian, penguapan air dan minyak terjadi secara bersamaan, sehingga disebut teknik penyulingan langsung (direct distilation). Uap air yang keluar dialirkan melalui kondensor (alat pendingin) agar menjadi cair (terkondensasi). Selanjutnya, cairan tersebut (campuran minyak dengan air) ditampung dan dibiarkan beberapa saat sampai cairan terpisah menjadi bagian air dan minyak. Bahan yang berat jenisnya lebih besar akan berada di bawah. Lalu, dengan membuka keran pada alat penampung, minyak dan air dapat dipisahkan. Teknik ini adalah yang paling sederhana dan tidak memerlukan banyak modal, namun teknik ini lebih cocok terhadap bahan yang jumlahnya tidak terlalu banyak. Ada beberapa kelemahan dari teknik ini, yaitu kualitas minyak yang dihasilkan cukup rendah, kadar minyak sedikit, dan produk minyak bercampur dengan hasil sampingan. 2. Penyulingan dengan air dan uap (dikukus) Teknik penyulingan ini menghasilkan kualitas dan produksi minyak esensial yang lebih baik dibandingkan dengan teknik direbus. Prinsip kerjanya adalah ketel penyulingan diisi air sampai batas saringan. Bahan baku diletakkan di atas saringan sehingga tidak berhubungan langsung dengan air yang mendidih, tetapi nantinya akan berhubungan dengan uap air. Oleh karena itulah, teknik ini disebut penyulingan tidak langsung (indirect distilation). Pada teknik ini, air yang menguap akan membawa partikel-partikel minyak dan dialirkan melalui pipa ke alat pendingin sehingga terjadi pengembunan dan uap air yang bercampur minyak akan mencair kembali. Selanjutnya, campuran ini dialirkan ke alat pemisah untuk memisahkan minyak dari air dengan membuka keran pada tabung pemisah. Teknik ini cocok untuk penyulingan bahan yang jumlahnya lebih banyak dibandingkan dengan teknik merebus. Teknik penyulingan ini sering dipakai petani untuk mendapatkan minyak dengan kualitas baik untuk diekspor dan alat-alatnya pun dapat dibuat sendiri oleh petani. 3. Penyulingan dengan uap (diuapkan) Teknik ini tergolong untuk penyulingan dalam skala perusahaan besar dan memerlukan biaya yang cukup besar karena memakai dua buah ketel dan sebagian besar peralatan memakai bahan stainless steel (SS) dan mild steel (MS). Biaya besar untuk pengadaan alat-alat sepadan dengan hasil minyak esensial yang diperoleh, dimana kualitas minyak jauh lebih sempurna dibandingkan dengan kedua teknik yang telah dijabarkan sebelumnya (Gambar 2). Prinsip kerja teknik ini sebenarnya hampir sama dengan teknik dikukus, namun antara ketel uap dan ketel penyulingan harus dipisah. Ketel uap yang berisi air dipanaskan, lalu uapnya dialirkan ke ketel penyulingan yang berisi bahan baku. Suhu uap diusahakan tidak lebih dari 1000 celcius, agar tidak terlalu panas dan dapat merusak hasil sulingan. Partikel-partikel minyak pada bahan baku terbawa bersama uap dan dialirkan ke alat pendingin. Di dalam alat pendingin terjadi proses pengembunan sehingga uap air yang bercampur minyak akan mengembun dan mencair kembali. Setelah itu, campuran ini dialirkan ke alat pemisah yang akan memisahkan minyak dari air. Dalam tabung pemisah, minyak akan berada di bagian atas karena berat jenisnya lebih ringan daripada air. Selanjutnya, dengan membuka keran pada tabung pemisah, air yang ada dalam tabung dapat dikeluarkan dan yang tertinggal dalam tabung hanya minyak hasil penyulingan3 (Gambar 3). KERJA EKSTRAK LAVENDER SEBAGAI MEDIA RELAKSASI Indra penciuman memiliki peran yang sangat penting dalam kemampuan kita untuk bertahan hidup dan meningkatkan kualitas hidup kita. Dalam sehari kita bisa mencium lebih kurang 23.040 kali1. Bau-bauan dapat memberikan peringatan pada kita akan adanya bahaya dan juga dapat memberikan efek menenangkan (relaksasi)1. Tubuh dikatakan dalam keadaan relaksasi adalah apabila otot-otot di tubuh kita dalam keadaan tidak tegang. Keadaan relaksasi dapat dicapai dengan menurunkan tingkat stres, baik stres fisik maupun psikis, serta siklus tidur yang cukup dan teratur. Minyak lavender dengan kandungan linalool-nya adalah salah satu minyak aromaterapi yang banyak digunakan saat ini, baik secara inhalasi (dihirup) ataupun dengan teknik pemijatan pada kulit. Aromaterapi yang digunakan melalui cara inhalasi atau dihirup akan masuk ke sistem limbic dimana nantinya aroma akan diproses sehingga kita dapat mencium baunya. Pada saat kita menghirup suatu aroma, komponen kimianya akan masuk ke bulbus olfactory, kemudian ke limbic sistem pada otak. Limbic adalah struktur bagian dalam dari otak yang berbentuk seperti cincin yang terletak di bawah cortex cerebral. Tersusun ke dalam 53 daerah dan 35 saluran atau tractus yang berhubungan dengannya, termasuk amygdala dan hipocampus. Sistem limbic sebagai pusat nyeri, senang, marah, takut, depresi, dan berbagai emosi lainnya. Sistem limbic menerima semua informasi dari sistem pendengaran, sistem penglihatan, dan sistem penciuman. Sistem ini juga dapat mengontrol dan mengatur suhu tubuh, rasa lapar, dan haus. Amygdala sebagai bagian dari sistem limbic bertanggung jawab atas respon emosi kita terhadap aroma. Hipocampus bertanggung jawab atas memori dan pengenalan terhadap bau juga tempat dimana bahan kimia pada aromaterapi merangsang gudang-gudang penyimpanan memori otak kita terhadap pengenalan baubauan1. Minyak lavender adalah salah satu aromaterapi yang terkenal memiliki efek menenangkan. Menurut penelitian yang dilakukan terhadap tikus, minyak lavender memiliki efek sedasi yang cukup baik dan dapat menurunkan aktivitas motorik mencapai 78%11, sehingga sering digunakan untuk manajemen stres. Beberapa tetes minyak lavender dapat membantu menanggulangi insomnia, memperbaiki mood seseorang, dan memberikan efek relaksasi. Penelitian lain yang dilakukan terhadap manusia mengenai efek aromaterapi lavender untuk relaksasi, kecemasan, mood, dan kewaspadaan pada aktivitas EEG (Electro Enchepalo Gram) menunjukkan terjadinya penurunan kecemasan, perbaikan mood, dan terjadi peningkatan kekuatan gelombang alpha dan beta pada EEG yang menunjukkan peningkatan relaksasi. Didapatkan pula hasil yaitu terjadi peningkatan secara signifikan dari kekuatan gelombang alpha di daerah frontal, yang menunjukkan terjadinya peningkatan rasa kantuk5. MANFAAT EKSTRAK LAVENDER Minyak lavender berwarna jernih sampai kuning pucat dengan bau wangi yang sangat khas12 . Minyak lavender adalah salah satu aromaterapi yang terkenal memiliki efek sedatif, hypnotic, dan anti-neurodepresive baik pada hewan maupun pada manusia6. Karena minyak lavender dapat memberi rasa tenang, sehingga dapat digunakan sebagai manajemen stres. Kandungan utama dalam minyak lavender adalah linalool asetat yang mampu mengendorkan dan melemaskan sistem kerja urat-urat syaraf dan otot-otot yang tegang. Dikatakan juga linalool menunjukkan efek hypnotic dan anticonvulsive pada percobaan menggunakan tikus6. Karena khasiat inilah bunga lavender sangat baik digunakan sebagai aromaterapi. Selain itu, beberapa tetes minyak lavender dapat membantu menanggulangi insomnia, memperbaiki mood seseorang, menurunkan tingkat kecemasan, meningkatkan tingkat kewaspadaan, dan tentunya dapat memberikan efek relaksasi. Wisatawan merupakan orang yang melakukan wisata ke berbagai tempat dengan tujuan untuk memperoleh kesenangan atau ketenangan. Tentunya para wisatawan memerlukan stamina dan kondisi tubuh yang selalu fit agar dapat menempuh perjalanan wisata yang nyaman. Oleh karena itu manfaat aromaterapi khususnya aroma lavender dengan kandungan zat yang dimiliki akan dapat memberikan kenyamanan bagi para wisatawan yang sedang melakukan perjalanan. Bagi orang yang sehari-harinya melaksanakan berbagai kesibukan dengan tingkat kelelahan dan stres yang tinggi serta kurangnya waktu yang dapat digunakan untuk beristirahat dan berwisata, dapat melakukan aromaterapi menggunakan teknik inhalasi aroma minyak lavender di rumah masing-masing, dengan meneteskan minyak lavender pada bantal ataupun memakai bantuan bakaran lilin aromaterapi. Selain karena manfaatmanfaat aromaterapi lavender yang sangat sesuai dengan kebutuhan, waktu yang diperlukan untuk melakukan teknik tersebut juga tidak banyak. Sehingga akan sangat memungkinkan bagi orang-orang yang tidak memiliki banyak waktu luang. Wisatawan memperoleh manfaat, dalam aspek fisik maupun psikis apabila melakukan aromaterapi menggunakan minyak lavender. Manfaat aspek fisik dari aromaterapi ini dapat merelaksasikan otot-otot yang kaku setelah melakukan perjalanan wisata yang cukup jauh. Aroma lavender juga memberikan efek sedatif yang cukup baik sehingga para wisatawan dapat beristirahat dengan cukup setelah melakukan perjalanan wisatanya dan dapat melakukan perjalanan wisata lain dengan kondisi tubuh yang lebih baik. Dari segi psikis, melihat adanya manfaat dalam memperbaiki mood dari minyak lavender, tentunya para wisatawan dapat melakukan wisatanya dengan perasaan yang tenang dan nyaman serta jauh dari depresi dan tekanan. Pemakaian minyak lavender sebagai aromaterapi telah dilakukan sejak zaman dahulu. Seiring perjalanannya, sempat dilaporkan bahwa ada beberapa efek samping yang ditimbulkan dari pemakaian minyak lavender secara inhalasi, diantaranya, mual, muntah, sakit kepala, dan menggigil. Dermatitis kontak dan phototoxicity juga dilaporkan terjadi pada penggunaan minyak lavender secara topikal12 . DISKUSI Penelitian yang dilakukan oleh Jeffrey J. Gedney, Psyd., Toni L. Glover, MA., RN., dan Roger B, Fillingim, PhD. dengan judul �Sensory and Affective Pain Discrimination After Inhalation of Esensial Oils�. Metode penelitian yang digunakan adalah randomized crossover design dengan melakukan penelitian 26 orang sehat, tidak merokok, dan tidak dalam pengobatan (13 laki-laki dan 13 wanita belum menopause). Dalam studi ini didemonstrasikan bahwa inhalasi dari minyak esensial lavender dan rosemary tidak menemukan hasil adanya efek analgesik. Tetapi evaluasi subjek secara retrospektif dari pengaruh aroma terhadap perubahan intensitas nyeri dan nyeri yang tidak mengenakkan menunjukkan mereka memperoleh manfaat yang menguntungkan, khususnya untuk lavender. Jadi dalam evaluasi klinis secara retrospektif tentang efektivitas treatment, aromaterapi dapat menimbulkan perubahan hubungan klinis pada laporan pasien mengenai rasa nyeri. Oleh karena itu kecenderungan efek samping yang diperoleh dari penelitian ini adalah bahwa aroma terapi dapat membantu dalam terapi yang berhubungan dengan nyeri dan adanya kerusakan jaringan2. Penelitian yang dilakukan oleh Miguel A. Diego, Nancy Aaron Jones, Tiffany Field, Maria Hernandez-Reif, Saul Schanburg, Cynthia Kuhn, Virginia McAdam, Robert Galamaga, dan Mary Galamaga, dengan judul �Aromatherapy Positively Affects Mood, EEG Patterns of Alertness, and Math Computations�. Dengan melakukan penelitian menggenakan aroma lavender dan rosemary pada 40 orang mahasiswa dan staf dari Universitas Miami Medical School, yang terdiri dari 30 wanita dan 10 laki-laki. Penelitian ini dibagi menjadi tiga tahap. Penelitian tahap pertama menggunakan data laporan langsung menunjukkan bahwa, kedua kelompok baik lavender maupun rosemary mengalami penurunan yang signifikan dalam score tingkat kecemasan yang dites menggunakan kuisioner STAI (State Anciety Inventory), hanya kelompok lavender yang mengalami perbaikan mood secara signifikan setelah pemberian aroma terapi, yang diketahui dari penurunan score POMS (The Profile of Mood States), kedua kelompok merasa lebih rileks, dan kelompok rosemary cenderung merasa lebih waspada. Penelitian tahap kedua menggunakan math computations menunjukkan bahwa kedua kelompok dapat mengisi math computations dengan lebih cepat setelah diberi aroma terapi, tetapi hanya kelompok lavender yang mengalami peningkatan ketelitian atau ketepatan dalam pengisian. Penelitian tahap ketiga menggunakan data EEG pada saat sebelum, selama, dan setelah menggunakan aroma terapi, hasilnya menunjukkan bahwa kelompok yang mengalami peningkatan gelombang alpha pada daerah frontal secara signifikan adalah kelompok lavender ditandai adanya peningkatan rasa kantuk, sementara kekuatan gelombang alpha pada daerah frontal menurun pada kelompok rosemary ditandai adanya peningkatan kewaspadaan, (2) Kedua kelompok aroma terapi mengalami peningkatan gelombang beta yang ditandai adanya rasa kantuk5. Kedua penelitian sama-sama menggunakan aroma lavender dan rosemary sebagai objek penelitian dan sama-sama meneliti efek yang diakibatkan oleh kedua aromaterapi tersebut. Penelitian pertama, meneliti efek aroma lavender dan rosemary terhadap rasa nyeri atau efek analgesik. Penelitian kedua meneliti efek aroma lavender dan rosemary terhadap perbaikan mood, kewaspadaan, dan pengaruh terhadap rasa kantuk. Menurut hasil dari beberapa jurnal penelitian, didapatkan kesimpulan bahwa minyak esensial dari bunga lavender dapat memberikan manfaat relaksasi (carminative), sedatif, mengurangi tingkat kecemasan, dan mampu memperbaiki mood seseorang. Belum terdapat jurnal yang membahas mengenai bagaimana mekanisme kerja linalool pada CNS (Central Nervous System) sehingga lavender dapat memberikan berbagai manfaat seperti tersebut di atas. RINGKASAN Kandungan utama dari bunga lavender adalah linalyl asetat dan linalool (C10H18O). Linalool adalah kandungan aktif utama yang berperan pada efek anti cemas (relaksasi) pada lavender. Minyak lavender dengan kandungan linalool-nya adalah salah satu minyak aromaterapi yang banyak digunakan saat ini, baik secara inhalasi (dihirup) ataupun dengan teknik pemijatan pada kulit. Minyak lavender adalah salah satu aromaterapi yang terkenal memiliki efek menenangkan, sehingga dapat digunakan sebagai manajemen stres. Menurut beberapa penelitian, minyak lavender lavender sendiri berpengaruh secara signifikan terhadap penurunan tingkat kecemasan, peningkatan relaksasi, dan peningkatan rasa kantuk, serta adanya perbaikan mood . DAFTAR PUSTAKA 1. Buckle J. Aromatherapy and Diabetes. Diabetes Spectrum 2001: vol. 4 no. 3; 124-126 2. Gedney JJ, Glover TL, Fillingim RB. Sensory and Affective Pain Discrimination After Inhalation of Esensial Oils. Psychosomatic Medicine 2004: 66; 599-606 3. Taufiq T. 2007. Menyuling Minyak Atsiri. PT. Citra Pramana: Yogyakarta 4. http://lilyflowers-8.blogspot.com/2009/05/bunga-lavender.html. Diakses tanggal 20 Januari 2011 5. Diego AM, Jones NA, Field T, Hernandez-Reif M, Schanberg S, Kuhn C, McAdam V, Galamaga R, Galamaga M. Arometherapy Positively Affects Mood, EEG Pattern of Alertness and Math Computations. International Journal of Neuroscience 1998: vol 96; 217-224 6. Yamada K, Mimaki Y, Sashida Y. Effect Inhaling of the Vapor of Lavandula burnatii super-Derrived Esensial Oil and Linalool on Plasma Adrenocorticotropin Hormone (ACTH), Catecholamine and Gonadotropin Level in Experimental Menopausal Female Rats. Pharmaceutical Society of Japan 2005: 28 (2); 378-379 7. McLain DE. Chronic Health Effects Assessment of Spike Lavender Oil. Walker Doney and Associates, Inc 2009; 1-18 8. Barocelli E, Calcina F, Chiavarini M, Impicciatore M, Bruni R, Bianchi A, Vallabeni V. Antinociceptive and Gastroprotective Effect of Inhaled and Orally Administered Lavandulahybrida Reverchon �Grosso� Esensial oil. Science Direct 2004: 76; 213-223 9. http://en.wikipedia.org/wiki/Aromatherapy. Diakses tanggal 20 Januari 2011 10. http://id.shvoong.com/social-sciences/counseling/2089560-khasiat-dan-manfaat- bungalavender/. Diakses tanggal 20 Januari 2011 11. Snow AL, Hovanec L, Brandit J. A Controlled Trial of Aromatherapy for Agitation in Nursing Home Patients with Dementia. The Journal of Alternatif and Complementary Medicine 2004: vol. 10 no. 3; 431-437 12. Sweetman SC. 2002. The Complete Drug Reference. Pharmaceutical Press: London 13. http://www.google.co.id/imglanding?q=alat+penyulingan+minyak&hl=en&gbv=2&tbs =isch:1&tbnid=5CFKsGwLBh3FhM:&imgrefurl=http://business.dinomarket.com/ads/9 14452/Jual-DESTILATOR-PENYULING-MINYAKATSIRI/& imgurl=http://media.dinomarket.com/docs/imgusr/mesindestilatorminyaknila m_ll.jpg.jpg&ei=_2k5TcP8OoLSsAOGwOn8Ag&zoom=1&w=500&h=314&iact=hc& oei=92k5TfyWDsysrAedj_2wCA&esq=2&page=2&tbnh=114&tbnw=182&start=20&n dsp=18&ved=1t:429,r:5,s:20&biw=1280&bih=588. Diakses tanggal 20 Januari 2011 14. http://www.google.co.id/images?hl=en&biw=1280&bih=588&gbv=2&tbs=isch%3A1& sa=1&q=alat+penyulingan+lavender&aq=f&aqi=&aql=&oq=. Diakses tanggal 20 Januari 2011 Gambar 1. Bunga Lavender7 Gambar 2. Alat Penyulingan dengan Uap13 Gambar 3. Alat Penyulingan Minyak Lavender14 Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing), Volume 8, No.2, Juli 2013 120 PENGARUH AROMATERAPI LAVENDER TERHADAP INTENSITAS NYERI PADA PASIEN PASCA OPERASI DI RUMAH SAKIT DUSTIRA CIMAHI Argi Virgona Bangun1, Susi Nur�aeni2 1,2 Program Studi Keperawatan Sekolah Tinggi Ilmu Kesehatan Jendral Achmad Yani Cimahi ABSTRACT Lavender as aromatherapy give effect of relaxing and sedation. Research aimed to know the influence of lavender aromatherapy on pain intensity on major surgical post operative patient. This research used pre-experimental design with one group pretest-posttest design form. Sample in this research as many as 10 people by purposive sampling technique and data analysis by paired t-test. Statistical test result obtained p value 0,001. There is seen a significance difference of pain intensity before and after lavender aromatherapy provision. Suggestion for Dustira Hospital Cimahi, research could become input for Hospital to applied lavender aromatherapy provision on post operative patient. Lavender aromatherapy should be taught before surgery, and patients can be applied in patients after surgery. Key Words : Aromatherapy, Lavender, Post Surgery Pain, Pain Intensity ABSTRAK Lavender sebagai aromaterapi memberikan efek relaksasi dan sedasi. Tujuan penelitian untuk mengetahui pengaruh aromaterapi lavender terhadap intensitas nyeri pada pasien pasca operasi. Penelitian ini menggunakan desain pre-eksperimental dengan bentuk rancangan one group pretest-posttest design selama Januari - April 2013 dengan sampel yang dipilih secara purposive sampling. Analisa data dengan uji paired t-test. Hasil uji statistik didapatkan nilai p value 0,001 berarti ada perbedaan intensitas nyeri antara sebelum dan sesudah diberikan aromaterapi lavender. Penelitian ini dapat menjadi masukan bagi Rumah Sakit untuk menerapkan pemberian aromaterapi lavender pada pasien pasca operasi. Kata kunci : Aromaterapi, Lavender, operasi, Intensitas Nyeri Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing), Volume 8, No.2, Juli 2013 121 PENDAHULUAN Pembedahan merupakan suatu tindakan pengobatan yang menggunakan cara invasif dengan membuka dan menampilkan bagian tubuh yang akan ditangani. Pembukaan bagian tubuh ini umumnya dilakukan dengan membuat sayatan. Setelah bagian yang akan ditangani ditampilkan, selanjutnya dilakukan perbaikan yang diakhiri dengan penutupan dan penjahitan luka. Setiap pembedahan selalu berhubungan dengan insisi yang merupakan trauma bagi penderita yang menimbulkan berbagai keluhan dan gejala. Salah satu keluhan yang sering dikemukakan adalah nyeri (Sjamsuhidajat & Jong, 2005). Adapun bentuk nyeri yang dialami oleh klien pasca pembedahan adalah nyeri akut. Nyeri akut secara serius mengancam penyembuhan klien pasca operasi sehingga menghambat kemampuan klien untuk terlibat aktif dalam mobilisasi, rehabilitasi, dan hospitalisasi menjadi lama (Perry & Potter, 2006). Nyeri setelah pembedahan merupakan hal yang fisiologis, tetapi hal ini menjadi salah satu keluhan yang paling ditakuti oleh klien setelah pembedahan. Sensasi nyeri mulai terasa sebelum kesadaran klien kembali penuh, dan semakin meningkat seiring dengan berkurangnya pengaruh anestesi. Adapun bentuk nyeri yang dialami oleh klien pasca pembedahan adalah nyeri akut (Perry & Potter, 2006). Tujuan dari manajemen nyeri pasca operasi adalah untuk mengurangi atau menghilangkan rasa sakit dan ketidaknyamanan pasien dengan efek samping seminimal mungkin. Salah satu intervensi yang efek sampingnya minimal adalah penatalaksanaan nonfarmakologi seperti stimulasi dan massase kutaneus, terapi es dan panas, stimulasi saraf elektrik transkutaneus (TENS), distraksi, teknik relaksasi, imajinasi terbimbing, hipnosis (Bare G & Smelzer C, 2002). Salah satu fungsi independen yang merupakan fungsi mandiri dan tidak tergantung pada petugas medis lain, dimana perawat dalam melaksanakan tugasnya dilakukan secara mandiri dengan keputusannya sendiri dalam melakukan tindakan dalam rangka pemenuhan kebutuhan dasar manusia (Hidayat, 2004). Aromaterapi adalah terapi komplementer dalam praktek keperawatan dan menggunakan minyak esensial dari bau harum tumbuhan untuk mengurangi masalah kesehatan dan memperbaiki kualitas hidup. Sharma (2009) mengatakan bahwa bau berpengaruh secara langsung terhadap otak seperti obat analgesik. Misalnya, mencium lavender maka akan meningkatkan gelombang-gelombang alfa didalam otak dan membantu untuk merasa rileks. Berdasarkan studi pendahuluan pada 10 orang pasien pasca operasi bedah mayor yang mendapatkan terapi analgesik dengan dosis dan cara pemberian yang sama didapatkan bahwa skala nyeri mereka ada pada rentang yang berbeda-beda. Selain itu diketahui bahwa upaya lain untuk mengatasi nyeri selain obat adalah hanya dengan melakukan relaksasi nafas dalam. Penelitian ini bertujuan untuk mengetahui pengaruh aromaterapi lavender terhadap intensitas nyeri pada pasien pasca operasi bedah mayor di Rumah Sakit Dustira Cimahi. METODE PENELITIAN Penelitian dilaksanakan di ruang perawatan bedah wanita RS Dustira Cimahi pada April sampai dengan Mei 2013. Penelitian ini menggunakan desain Quasi-experimental dengan one group Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing), Volume 8, No.2, Juli 2013 122 pretest posttest. Responden terdiri dari 10 orang pasien paska operasi bedah mayor hari ke-2 yang tidak memiliki riwayat dioperasi sebelumnya, berusia 18-45 tahun, jenis kelamin perempuan, dan mendapatkan jenis analgetik yang serupa. Responden dikaji skala nyerinya menggunakan Verbal Descriptor Scale (VDS) lalu diberikan aroma terapi lavender sebanyak 3 tetes dengan menggunakan pembakar minyak dan tungku selama 10 menit. Responden diminta bernafas normal, tidak melakukan aktivitas lain selama menghirup aroma terapi, dalam kondisi ruangan yang tenang. Selanjutnya satu jam kemudian skala nyeri diukur kembali. Analisis bivariat dilakukan melalui uji paired t-test. HASIL DAN BAHASAN Tabel 1. Rerata Intensitas Nyeri Pasien Pasca Operasi Sebelum Pemberian Aromaterapi Lavender di Rumah Sakit Dustira Cimahi. Variabel Mean SD Minimum Maksimum 95%CI Intensitas Nyeri Sebelum Aromaterapi Lavender 4,80 2,530 2-10 2,99 6,61 Dari hasil analisa tabel 1 terlihat bahwa intensitas nyeri sebelum diberikan aromaterapi lavender 4,80, dengan intensitas nyeri terendah 2 dan tertinggi 10. Dari tingkat kepercayaan pasien disimpulkan bahwa 95% diyakini bahwa rata-rata intensitas nyeri antara 2,99 sampai 6,61. Hasil penelitian ini sejalan dengan penelitian yang telah dilakukan oleh Marzouk, et al (2012) yang menunjukkan bahwa kombinasi dari efek lavender dengan analgesik, sedatif, dan antikonvulsan dapat mengurangi nyeri efek anestesi lokal serta penelitian Maryati (2010) menunjukan bahwa aromaterapi lavender berpengaruh terhadap nyeri haid primer dengan nilai p=0,000, p value < a (a=0,05). McCaffery (2009) mendefinisikan nyeri sebagai �orang yang mengalami nyeri dalam segala hal dan terjadi kapan saja orang tersebut mengatakan bahwa ia merasakan nyeri� (Kozier, et al. 2009). Berdasarkan International Association For Study of Pain (IASP), nyeri adalah sensori subjektif dan emosional yang tidak menyenangkan yang didapat terkait dengan kerusakan jaringan aktual maupun potensial, atau menggambarkan kondisi terjadinya kerusakan (Lyndon, 2013). Nyeri setelah pembedahan merupakan hal yang fisiologis, tetapi hal ini merupakan salah satu keluhan yang paling ditakuti oleh klien setelah pembedahan. Sensasi nyeri mulai terasa sebelum kesadaran klien kembali penuh, dan semakin meningkat seiring dengan berkurangnya pengaruh anestesi. Adapun bentuk nyeri yang dialami oleh klien pasca pembedahan adalah nyeri akut yang terjadi karena adanya luka insisi bekas pembedahan (Perry dan Potter, 2006). Pada nyeri pasca bedah rangsangan nyeri Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing), Volume 8, No.2, Juli 2013 123 disebabkan oleh rangsangan mekanik yaitu luka (insisi) dimana insisi ini akan merangsang mediator-mediator kimia dari nyeri seperti histamin, bradikinin, asetilkolin, dan substansi prostaglandin dimana zat-zat ini diduga dapat meningkatkan sensitifitas reseptor nyeri yang akan menimbulkan sensasi nyeri. Selain zat yang mampu merangsang kepekaan nyeri, tubuh juga memiliki zat yang mampu menghambat (inhibitor) nyeri yaitu endorfin dan enkefalin yang mampu meredakan nyeri (Bare G & Smelzer C, 2002). Hasil penelitian menunjukan bahwa rata-rata intensitas nyeri pasien pasca operasi bedah mayor sebelum pemberian aromaterapi lavender adalah antara 2,99 sampai 6,61. Hal itu bermakna mereka merasa nyeri ringan sampai dengan nyeri hebat tak tertahankan. Tujuan dari manajemen nyeri pasca operasi adalah untuk mengurangi atau menghilangkan rasa sakit dan ketidaknyamanan pasien dengan efek samping seminimal mungkin. Pendekatan farmakologi merupakan tindakan kolaborasi antara perawat dengan dokter, yang menekankan pada pemberian obat yang mampu menghilangkan sensasi nyeri. Sedangkan strategi penatalaksanaan nyeri nonfarmakologi dapat diterapkan berbagai tindakan keperawatan holistik. Pada implementasi trapi holistik di Indonesia, strategi tindakan holistik dipandang sebagai tindakan komplementer (Perry & Potter, 2006). Tabel 2. Rerata Intensitas Nyeri Pasien Pasca Operasi Sesudah Pemberian Aromaterapi Lavender di Rumah Sakit Dustira Kota Cimahi. Variabel Mean SD Minimum Maksimum 95%CI Intensitas Nyeri Sesudah Aromaterapi Lavender 4,10 2,807 1-10 2,09 6,11 Dari hasil analisa tabel 2 intensitas nyeri sesudah diberikan aromaterapi lavender 4,10, dengan intensitas nyeri terendah 1 dan tertinggi 10. Dari tingkat kepercayaan pasien disimpulkan bahwa 95% diyakini bahwa rata-rata intensitas nyeri antara 2,09 sampai 6,11. Dipandang dari segi biaya dan manfaat, penggunaan manajemen nonfarmakologi lebih ekonomis dan tidak ada efek sampingnya jika dibandingkan dengan penggunaan manajemen nyeri farmakologi. Selain itu juga mengurangi ketergantungan pasien terhadap obat-obatan. Perawat mengajarkan keperawatan mandiri atau terapi komplementer kepada pasien atau keluarga pasien. Salah satu terapi komplementer adalah aromaterapi, dimana aromaterapi ini bermanfaat mengurangi ketegangan otot yang akan mengurangi tingkat nyeri. Hasil penelitian menunjukan penurunan bermakna dari intensitas nyeri paska pemberian aromaterapi Lavender, yaitu 2,09 sampai 6,11. Bau yang merupakan stimulan ingatan yang sangat Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing), Volume 8, No.2, Juli 2013 124 kuat, secara spontan memberikan tandatanda emosi yang disebabkan karena keunikan dari sistem penciuman yang berhubungan langsung dengan sistem limbik dan emosi kita (Romantyo & Harini, 1999) Sistem limbik adalah bagian dari otak yang dikaitkan dengan suasana hati, emosi, memori, dan belajar kita. Semua bau yang mencapai sistem limbik memiliki pengaruh langsung pada suasana hati kita (Sharma, 2009). Tabel 3. Pengaruh Aromaterapi Lavender Terhadap Intensitas Nyeri Pada Pasien Pasca Operasi Bedah Mayor di Rumah Sakit Dustira Kota Cimahi. Variabel Mean SD Perbedaan Rata-rata P Value N Intensitas Nyeri Pre Post 4,80 4,10 2,530 2,807 0,700 0,001 10 Dari hasil analisa tabel 3 didapatkan bahwa rerata intensitas nyeri sebelum pemberian aromaterapi lavender adalah 4,80 dengan standar deviasi 2,530. Intensitas nyeri sesudah pemberian aromaterapi lavender 4,10 dengan standar deviasi 2,807. Terlihat nilai mean perbedaan rata-rata sebelum dan sesudah adalah 0,700. Hasil uji statistik didapatkan perbedaan yang signifikan karena nilai p = 0,001, p value < a (a = 0,05). Maka dapat disimpulkan ada perbedaan yang signifikan rata-rata sebelum dan sesudah pemberian aromaterapi lavender. Aromaterapi lavender bermanfaat untuk relaksasi, kecemasan, mood, dan pasca pembedahan menunjukkan terjadinya penurunan kecemasan, perbaikan mood, dan terjadi peningkatan kekuatan gelombang alpha dan beta yang menunjukkan peningkatan relaksasi. Gelombang alpha sangat bermanfaat dalam kondisi relaks mendorong aliran energi kreativitas dan perasaan segar dan sehat. Kondisi gelombang alpha ideal untuk perenungan, memecahkan masalah, dan visualisasi, bertindak sebagai gerbang kreativitas seseorang. Minyak lavender adalah salah satu aromaterapi yang terkenal memiliki efek menenangkan. Menurut penelitian yang dilakukan terhadap tikus, minyak lavender memiliki efek sedasi yang cukup baik dan dapat menurunkan aktivitas motorik mencapai 78%, sehingga sering digunakan untuk manajemen stres. Beberapa tetes minyak lavender dapat membantu menanggulangi insomnia, memperbaiki mood seseorang, dan memberikan efek relaksasi. Pendapat ini juga didukung oleh Sharma (2009) yang menyatakan bahwa lavender bersifat analgesik; untuk nyeri kepala, nyeri otot, bersifat antibakterial, antifungal, antiinflamasi, antiseptik, dan penenang. Sejauh ini tidak ada kontraindikasi yang diketahui dan tidak terdapat iritasi jika digunakan pada kulit dan juga tidak mengiritasi mukosa. Bahwa mencium lavender maka akan meningkatkan gelombang-gelombang alpha didalam otak dan membantu untuk merasa rileks. Hasil penelitian juga memperlihatkan bahwa ada 3 responden dengan skala nyeri yang tetap sesudah Jurnal Keperawatan Soedirman (The Soedirman Journal of Nursing), Volume 8, No.2, Juli 2013 125 diberikan aromaterapi lavender. Menurut data yang peneliti lakukan, semua responden menyukai wangi aromaterapi lavender. Walaupun semua responden menyukai wangi aromaterapi, ada 3 responden intensitas nyerinya tetap. Hal ini terjadi dikarenakan perbedaan karakteristik nyeri yaitu 2 responden mengalami nyeri yang berlangsung lama sampai merintihrintih kesakitan, gelisah, dan menangis. Sedangkan 1 responden hanya gelisah saja. Diagnosa medis responden pertama yaitu HNP lumbal skala nyerinya 10, responden kedua yaitu amputasi dengan DM type II skala nyerinya 3, dan responden ketiga yaitu cholelitiasis skala nyerinya 7. Usia dari 3 responden ini 45 tahun dan usia ini paling tua dibanding dengan 7 responden yang lain. Sesuai dengan (Perry & Potter, 2006), usia merupakan variabel penting yang mempengaruhi nyeri. Perbedaan perkembangan dan kesensitifan terhadap nyeri, yang membuat hasil intensitas nyerinya tetap berbeda dengan 7 responden yang hasil intensitas nyerinya berkurang. Responden yang mengalami skala tetap, setelah dihubungkan dengan konsep dari teori dalam keperawatan akan sesuai dengan pengertian nyeri adalah sebuah sensasi subjektif sehingga tidak ada dua orang yang berespons dengan cara yang sama. Nyeri dapat secara langsung mengganggu kesehatan dan memperlama penyembuhan dari pembedahan, penyakit, dan trauma. Seseorang mendapat suatu stresor, dalam hal ini nyeri maka orang tersebut akan berespon untuk mempertahankan kesehatannya (mengurangi nyeri). Sehingga responden akan menggunakan kopingnya untuk memenuhi kebutuhan rasa nyamannya Gaffar (1999, dalam Yudistira, 2011). SIMPULAN DAN SARAN Aromaterapi lavender berpengaruh dalam penurunan intensitas nyeri pada pasien pasca operasi bedah mayor ditandai dengan penurunan nilai rata-rata intensitas nyeri sebelum dan sesudah diberikan aromaterapi lavender. Perawat perlu mengintegrasikan hasil penelitian ini sebagai salah satu intervensi dalam asuhan keperawatan pada pasien paska operasi. Perawat juga perlu mensosialisasikan penggunaan aromatrapi lavender kepada pasien, keluarga, dan masyarakat melalui pemberian pendidikan kesehatan. Desain penelitian dapat dicoba ulang dengan melibatkan kelompok kontrol dan kelompok intervensi dan menambah jumlah sampel. DAFTAR PUSTAKA Baradero, M. et al. (2009). Prinsip & Praktik Keperawatan Perioperatif. Jakarta: EGC Bare G & Smelzer C. (2002). Buku Ajar Keperawatan Medikal-Bedah Brunner & Suddarth. Jakarta: EGC Budiman. (2011). Penelitian Kesehatan. Bandung: Refika Aditama Dahlan, S.M. (2009). Statistik Untuk Kedokteran dan Kesehatan. 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