]ournal of Advanced Nursing, 1994, 19, 89-96

The role of lavender oil in relieving

perineal discomfort following childbirth: a
blind randomized clinical trial
Ailsa Dale RN RM
Midwifery Sister

and Sheila Comwell RN RM Dip Aromatherapy

Midwifery Sister, Hinchingbrooke Hospifal, Huntingdon, Cambridgeshire, England

Accepted for publication 25 May 1993

DALE A. & CORNWELL S. (1994) ]ournu! of Advanced Nursing 19,89-96

The role of lavender oil in relieving perineal discomfort following
childbirth: a blind randomized clinical trial
Aromatherapy is a movement growing in popularity, but laclung scientific
justification in the field of practice, although laboratory experiments are in
evidence. Lavender oil is frequently selected for aromatherapy as having
antiseptic and healing properties. More specifically, it has been used as a bath
additive postnatally to reduce perineal discomfort. A blind randomized clinical
trial is described, involving three groups of mothers, one using pure lavender
oil, one a synthetic lavender oil and one an inert substance as a bath additive
for 10 days following normal childbirth. Analysis of daily discomfort scores
revealed no statistically significant daerence between groups. It cannot be
concluded that current practice results in a reduction of postnatal perineal
discomfort at the dilution levels used. However, there is some consistency in
results between the 3rd and 5th days, with those women using lavender oil
as a bath additive recording lower mean discomfort scores. This is a time
when the mother usually finds herself discharged home and perineal
discomfort is high. A total of 635 women participated and no side-effects
were found.

INTRODUCTION ways of relieving discomfort, but have limited effect. The

use of salt or Savlon@ as an additive to bath water, to
Considerable perineal trauma and discomfort can be
prevent infection, promote healing and so reduce discom-
caused to mothers as a result of childbirth (Sleep et al.
fort, have been popular practices in midwifery, but have
1984). Even when tearing of tissues does not occur, a
been shown to be quite ineffective (Sleep & Grant
variable amount of soreness - sometimes severe -is
1988b).
experienced.
More recently, there has been a growing interest, both
The distress to women can be considerable. In hospital
in other European countries and also in parts of the UK,
the application of ice packs to the perineum, bathing and
in the use of oil extracted from lavender. One practice
the use of drugs such as paracetamol and codydramol
involves adding such oil to the bath water of mothers
(Hutchins et al. 1985, Sleep & Grant 1988a,b)are popular
daily for up to 10 days following the birth of the child.
Corrrspondmce: Ailsa Duk,Midwifm/ Sisfcr, Hinchingbrooke Hospiful, Hinching-
The claims made for the practice are that perineal
brooke Park, Huntingdon, Cambridgeshire PEI8 8NT, England. discomfort for the mother is reduced compared with its

89
A. Dale and S. Cornwell
non-use. No such claims are made for synthetic lavender
oil, which on visual and olfactory inspection is very
similar. These claims made for lavender oil, however, lack
any scientific basis. This investigation seeks to remedy
this position.
A clinical trial was undertaken using three groups of
mothers, one using an extract of lavender oil as a bath
additive, one using a synthetic laboratory-produced oil
and a final control group using a 'generally regarded as
safe' (GRAS) compound (2-Methyl 3-Isobutyl Pyrazine)
diluted 10 - lo in distilled water as an inert but aromatic
placebo (Bureau de Liaison 1990). The latter was chosen
since the pure and synthetic oils both had odours, and it
was felt important that the placebo should not be
odourless.
THE LITERATURE
Lavender oil is distilled from the flowering tops of the
plant. Its main constituents are dbomeol, caryphyllene,
cineol, coumarin, geraniol, limonene, linalol acetate,
I-pinene and the esters of geranyl, linalyl, butyric acid
and valerianic acid. The oil has been used for centuries in
perfumery and for traditional medicinal purposes. Its
phenol-related compounds may account for its claimed
antiseptic properties. It is considered to be very safe, and
to be non-hazardous in terms of toxicity, sensitization
and irritation. It can even be taken safely internally up to
'500mg daily per kg body weight (Berkow et al. 1980,
Reynolds ef al. 1982).
Explanatory hypotheses for lavender oil's properties in
reducing perineal discomfort -if indeed it has any -
are of two kinds. The first, perhaps less persuasive, are
based on holistic approaches to medicine and supported
by a growing body of largely descriptive case study
evidence from uncontrolled studies. These studies are
described in growing literature on the subject (see
Bibliography). Amongst the second kind are possible
effects on the individual's immune system. One of these
theories suggests that minute quantities may be absorbed
through the skin and act on the thymus, so stimulating
the immune system (Lautie & Passebecq 1984).
Lavender oil would appear to be a safe substance
to use, If found to have any effect it would represent a
safe, pleasant, non-invasive and relatively inexpensive
method for reducing maternal perineal discomfort follow-
ing childbirth. It use could be suggested by midwifery
staff and self-administered by the mother.
The research question was therefore whether or not
mothers adding six drops of pure lavender oil to their
daily bath for 10 days postnatally would suffer less
90
perineal discomfort than a group of mothers not using
the preparation.
FORMAT OF THE INVESTIGATION
A blind clinical trial involving three groups of mothers
was planned. Current practice makes claims only for pure
lavender oil but not for synthetic oil, although the basis
for both the claim and the distinction is difficult to
identify in the literature. It made sense, therefore, to have
two groups, one using pure and one using synthetic
lavender oil respectively, and another group using an
inert aromatic compound for which no claims are made,
as a 'control' group.
Preliminary investigations and sample size
For a limited period lavender oil was used as a bath water
additive on a postnatal ward at Hinchingbrooke Hospital.
During this period, consumer-oriented quality assurance
was in progress. Mothers were asked -in a follow-up
questionnaire after discharge -if they had used the
additive and, if so, if they had found it relieved perineal
discomfort. Overall, 85% of those that used it claimed
that it had reduced perineal discomfort (Mulgrew 1989).
Clearly this result was highly subjective, and suffered
from the absence of adequate controls. There is no way
of knowing whether a bath alone would have given equal
relief.
Further small-scale sample data were collected to
establish possible measures of perineal discomfort, also
with the idea of estimating the sample size required for
the trial. For dependent variable measures of discomfort,
visual analogue scales WAS) were considered. Some
criticism can be levelled at the use of VAS as a measure
for recording perineal discomfort. This criticism revolves
around the fact that it is not an 'objective' measure.
However, the decision was eventually made to use such
measures on the basis of their reported success in
measuring feeling (Aitken 1969) both in experimental
situations (Duncan ef al. 1989) and in clinical practice
(Banos et al. 1989) compared with verbal rating methods.
The women in the pilot study found VAS straightfor-
ward and easy to complete. Sample data proved to be
normally distributed (using a Shapiro-Wik equivalent
test). The sample data yielded a mean of 38.5 and an SD
of 23.7. To achieve a 90% power for a difference of 10
points in mean scores between groups using a 5% test, a
sample size of 119 in each group would be required
(Pocock 1986).
 Lavender oil and pm‘neal discomfort

Table 1 Variables included in the study Variables 1and 2 were completed daily by the mother,
3-8 by the attending midwife in hospital, 9-11 by the
1 Daily discomfort VAS score (10days) mother on the loth day and 12-18 by the community
2 Daily mood VAS score (10days)
midwife on the final visit.
3 Group to which mothers were randomly allocated
4 Parity: primiparouslmultiparous
5 Delivery type instrumentdnormal T R IA L PROCEDURE
6 Perineum: 1st to 3rd degree tear, episiotomy (intact Patient consent
excluded)
Approval for the trial was sought and obtained from the
7 Sutures: yeslno
8 Sutured by: doctor/midwife Ethical Committee. Batches of the three bath additives
9 Used additive on 10th day: yeslno were prepared in a laboratory, and delivered to the
10 Obstetric
Used other medication for pain relief during the 10 days: Unit. The authors and staff in the unit were not
yeslno informed of the identity of the three batches until after
11 What helped discomfort most: tablets/ointmentlice the data analysis for the trial was completed. The control
packsbathlother ‘GRAS’ compound was distinguishable from the other
12 Day perineum healed by: day 1-10 two by olfactory inspection. However, mothers entering
13 Use of additive each day: yes/no the trial were informed that the trial was of different bath
14 Perineal bruising apparent: yes/no additives, and not of lavender oil. From this perspective
15 Haemorrhoids: yeslno
Sutures removed: yeslno
the smell of the oil was not especially important. Never-
16
17 Infection presentlabsent theless, in a ’perfumery’ sense the GRAS compound did
18 Antibiotics used: yeslno not smell as ‘pleasant’ as the lavender and the synthetic
lavender oils. The additives did not colour the bath
water.
Antenatal visits of Midwives clinics and to the
The difference of 10 points between means to estimate Maternity Unit were routinely made for those booked for
sample size was selected to reflect a difference which confinement. During the course of these visits women
would be important in a clinical midwifery sense. were made aware that a trial of bath additives might be in
progress at the time of their confinement.
Following delivery, prior to the mother’s first bath, the
The hypothesis trial was explained by the attending midwife. A consent
form was signed if the mother decided to enter the trial.
More formally, the hypotheses tested could be expressed Women were reassured that they could withdraw, with-
thus: out prejudice, from the trial at any time. The mother was
then randomly allocated to one of the three groups. Each
Null hypothesis mother was at this point issued with a 5-ml bottle of one
There is no difference in the mean discomfort scores of of the three additives, and her name was written on it.
women in the three groups using different preparations as The midwife also explained in detail to the mother the
bath additives. method for completing the VAS scale to record her
discomfort and mood daily, half an hour after her daily
bath.
Variables included in the study
Ward procedure
In adltion to the independent variable (the group to
which the mother was randomly allocated) and the Daily bathing is a routine part of the mother’s care after
dependent variable (mother’s daily VAS score of perineal delivery. For each day the mother bathed in hospital, the
discomfort) it was clear that a variety of extraneous midwife ensured that six drops of the oil from the
variables could potentially influence the mother’s experi- mother’s named bottle was added to the bath. Half an
ence of perineal discomfort. Clearly one such variable hour after having the bath, the mother was asked to
might be the mother’s mood. All the variables included complete the VAS record indicating the degree of dis-
are shown in Table 1. In randomly allocating mothers to comfort being experienced. The state of the perineum
the three groups one hopes to achieve similar distribution was assessed as part of the midwife’s normal daily
of these variables between groups. examination of the mother.

91
A. Dale and 5. Cornwell

Table 2 ‘No outcome’ rates

in study
Additive group
Lavender Synthetic Control Total
Status n (%) n (%) n (%) n (%)

Completed 134 (61.8) 132 (62.0) 120 (58.5) 386 (608)

No outcome 83 (38.2) 81 (38.0) 85 (41.5) 249 (39.2)

Total 217 (100.0) 213 (100.0) 205 (1000) 635 (100.0)

X2=0.646; d.f.=2; P=0.7241.

Prior to transfer home the mother was prepared by the
midwifery staff to continue the bathing procedure, and
was given a reference sheet to take home with her.
Following transfer home
Daily visits by the community midwife provided some
opportunity to reinforce the procedure with the mother,
and for assessment of the perineum to be continued until
the loth day.
At the last visit to the mother the community midwife
collected completed visual analogue scales and question-
naires from her, and collated them with the midwifery
records for return to the department. This process
worked well with mothers residing within the Health
District served by the local community services, but less
well when mothers were resident outside the Health
District.
The sample
Mothers entered the trial sample as outlined in the
sections above. They were entered during the trial period
if they had delivered vaginally. Excluded from the sample
were:
those delivered by Caesarian section,
those with active skin disorders such as eczema or
psoriasis,
those having stillbirths or neonates who were criti-
cally ill,
those without bathing facilities at home,
those not wishing to participate.
No-outcome subjects
Table 2 below shows the extent of non-returned data
during the trial period. The percentage varied between
groups from 38.0%to 41.5%.It proved difficult to make
a distinction between ‘withdrawals’ and ‘non-returns’ in
practice. Essentially, both groups comprised cases from
whom no outcome data were received. Particular diffi-
culty was experienced in obtaining returns from mothers
who resided out of the Health District, but chose to
deliver at Hinchingbrooke Hospital, and were therefore
included in the study. These represent LO%, and some-
times 30% of bookings in any month, due to the
popularity of the unit.
Women were deemed to have had ’no outcome’ if
efforts to retrieve the data records had failed after a
period of 2 months following delivery. They were
then replaced, maintaining the random allocation of
women to the three groups. The rate of non-return of
outcome data did not seem to be related to treatment
allocation.
Deciding when to stop recruitment was a difficult
decision given the non-completion rate. Attempts were
made to contact mothers whose data sheets had not been
returned. When contact was made the most common
reason given for non-return was that the mother had not
wished to continue bathing daily.
In making a comparison of mothers who returned no
data with those who did, no differences were found in
terms of bath data. There were no significant differences
in terms of parity (xz=2.219; d.f.=< P=01363), tears/
episiotomy (x2=0.585; d.f.= I; P=0.4443), whether they
were sutured (x2= 1.466; d.f. = 1; P=0.2260) or whether
they had a normal or instrumental delivery (x2=0.227;
d.f.= I; P=0*6337).
Statistical methods
Data were analysed using SPSS/PC+ Version 3.1. Analy-
sis of variance was used for the analysis of discomfort and
mood scores, which were tested and found to be nor-
mally distributed and x2 for the analysis of other nominal
level variables.

92
 Lavender oil and perineal discomfort

Table 3 Outcome variables, by group

Lavender Synthetic GRAS

Variable n (%I n (%I n (96) P

Initial variables
Multiparious 581134 (44.3) 601133 (45.1) 671120 (55.8) 0.1011
Instrumental 151134 (I1.2) 141133 (10.5) 71120 (5.8) 0.2842
Episiotomy 581134 (43.3) 521133 (391) 461120 (40.3) 0.8582
Sutured 1301135 (97.0) 132/133 (992) 1201120 (100.0) 0.0869
Sutured by midwife 108/131 (82.4) 144/131 (87.0) 103/120 (85.8) 0.5597
Outcome variables
Used no other medication 601134 (44.8) 631128 (49.2) 591118 (50.0) 0.3718
Bath helped most 791124 (63.7) 791120 (65.8) 671109 (61.5) 0.9914
Bruising 31121 (2.5) 51124 (4.0) 4/107 (3.7) 0.7791
Haemorrhoids 291123 (23.6) 251125 (20.0) 221108 (20.4) 0.7555
Sutures removed 261121 (21.5) 201125 (16.0) 201109 (18.3) 0.5408
Infection 111123 (8.9) 51124 (4.0) 31109 (2.8) 0.0811
Antibiotics 161123 (13.0) 91124 (7.3) 101109 (9.2) 0.3043
Day healed (1-10) (Kruskal-Wallis test=0.138) 0.9331
Used additive loth day 124/134 (92.5) 1171126 (92.9) 101/115 (878) 0.3071
Did not use additive daily 4123 (3.3) 81125 (6.4 14/109 (87.2) 0.0175

RESULTS 0.8% to 2.3%. In the second period of 4 days it

Mood scores were analysed to determine their distribu-
tion between groups as a potential extraneous variable.
Over the 10 days the daily mean scores for groups varied
between 74.60 and 85.41. There were no statistically
significant differences between groups (F varying be-
tween 0.0206 (Pz0.9797)and 0.9943 (P=0.3710).
Table 3 shows the distribution of the initial variables
and outcome variables by group.
The effect of randomization was to .distribute poten-
tially extraneous variables non-significantly (i.e. at the
005 level) between groups (Table 3). This process was
successful in 14 of the 15 instances. The exception was in
the case of the mothers in the sample using the additive
on each and every day. In this instance 14 in the GRAS
group did not use it every day as against four in the
lavender oil group, and eight in the synthetic oil group.
The reason for this may be the less ‘pleasant’ smell of the
GRAS compound discussed earlier.
Missing data
As with most field studies, small amounts of data were
missing due to incomplete records. These missing data
were minimal in the first 5 days of mothers completing
their discomfort records, varying between the days from
ranged from 1.8% to 4.7%, rising to 7.0% on the final
loth day.
During the 10-day period the mean discomfort scores
of the sample showed a steady reduction, commencing
with a mean score of 56.11 and dropping to 18-83on the
10th day. The proportion of missing data was therefore
related to the mothers’ reducing discomfort scores, sug-
gesting that as they improved they were more likely to
fail to record the amount of discomfort they experienced.
Perineal discomfort
The mean daily discomfort scores for the mothers in the
three groups were analysed to determine if there were
any statistically significant differences between group
scores (see Table 4).
Clearly, although women in the group using pure
lavender oil as an additive show lower mean discomfort
scores for the first 5 days following childbirth, any
diEference failed to achieve statistical significance. The
null hypothesis is therefore accepted; there is no sigrufi-
cant difference between the groups.
Effect size
Whilst there is no statistically significant difference be-
tween mean discomfort scores of the three groups over

93
A. Dale and S. Cornwell

Table 4 Mean discomfort

Day Group n Mean SD 95% CI F P
scores and 95% confidence
intervals, by group
I Lavender oil 132 5453 26.46 50.66-5986 05992 05498
Synthetic oil 129 58.12 2922 51.15-62-32
Control 115 55.68 25.00 50.45-60.28
2 Lavender oil 132 50.85 25.36 4993-55.06 0.0588 0.9429
Synthetic oil 135 51.93 26.95 46.52-5674
Control 119 5 1.35 25.15 46.56-56.28
3 Lavender oil 133 43.71 22.45 38.61-46.81 1.8365 0.1608
Synthetic oil 132 48.27 26.56 42.76-52.69
Control 118 49.21 24.82 43.39-53.18
4 Lavender oil 13 1 40.97 24.30 35.14-43.94 1.9619 0.1420
Synthetic oil 129 46.25 25.60 41.52-5 1.12
Control 118 46.65 26.99 40.74-50.71
5 Lavender oil 134 30.46 23.07 32.23-4041 1.7830 0.1695
Synthetic oil 132 40.77 25.88 3678-46.2I
Control 118 42.I7 27.00 36-41-46.6 7
6 Lavender oil 132 34.09 23.30 2911-3 7.59 0.2942 07453
Synthetic oil 13 I 34.53 22.27 29.86-3 7.90
Control 117 36.28 25.28 30.6440.35
7 Lavender oil 132 30.53 24.23 26.15-35.04 0.1922 0.8252
Synthetic oil 129 29.54 21.65 2434-32.48
Control I16 3 1.42 25.33 25.95-35.76
8 Lavender oil 131 27-08 25-02 21.92-304 I 0.1448 0.8653
Synthetic oil 130 25-78 21.57 21.7&2956
Control 112 27.29 25.79 22.38-32.90
9 Lavender oil 130 24-63 26.05 19.07-28.37 0.0707 09318
Synthetic oil 125 24-23 24.08 19.90-28.77
Control 114 23-44 24.77 18.43-28.17
10 Lavender oil 126 19.45 23.13 15.10-23.29 0.1581 08538
Synthetic oil 124 17.90 21.39 14.66-22.84
Control 110 19.16 24.61 14.31-23.71

the 10-day period, there are some consistently lower
mean scores in the lavender oil group, particularly
between days 3 and 5. Kazis ef af. (1989) have discussed
the fact that statistical significance may occur but have
little clinical relevance and equally items of clinical
significance may not be demonstrably statistically signifi-
cant. They propose that an analysis of effect size can help
to standardize the magnitude of differences between
mean scores. In general terms an effect size of 0.2 is
considered small, one of 0.5 moderate and one of 0.8 to
be large. The effect size of differences between day 1 and
day 10 within each group are shown in Table 5.
Clearly the effect size increases over time within each
group consistently. This pattern is not unexpected as
perineal discomfort decreases over time. The pattern of
effect sizes is also consistent within each group. How-
ever, more important is the effect sizes between the
lavender oil group and the GRAS (control) group. These
are shown in Table 6. They show very similar small
values over the 10 days, indicating no differences
between the groups.
Secondary analysis
A second analysis of data was undertaken along the lines
suggested by Matthews ef al. (1990) and published after
this study began. They argue that fuller use of data for a
set of measures gathered over time can be made by
calculating summary measures for individuals in the
study. In the case of the data gathered in the course of
this study the main issue is whether the decrease in
discomfort scores occurs more speedily in one group of
mothers than another. Measuring a fall to a percentage of
the individual's initial score seemed particularly appropri-
ate, and a fall of 50% seemed a natural level to choose

94
 Lavender oil and perineal discomfort

Table 5 Wect size within groups over 10 days, using day 1 as Table 7 Distribution of cases with and without a 50%
a baseline reduction in discomfort scores, by group

Day Lavender Synthetic GRAS Reduction Lavender Synthetic G W

1 - - - 50% or larger 108 105 95

2 0.14 0.21 0.17 Below 50% 24 23 19
3 0.41 0.34 0.26
Total 132 128 114
4 0.51 0.41 0.36
5 0.68 059 0.54
6 0.77 0.81 0.78
7 0.91 0.98 0.97
8 1.04 1.11 1.14 Table 8 Distribution of cases achieving a 50% reduction in
9 1.13 1.16 1.29 discomfort scores, by group
10 1.33 1.38 1.46 ~

Day Lavender Synthetic GRAS

Table 6 Effect sizes between lavender oil and GRAS (control) 1 (baseline) - - -
groups 2 14 11 13
3 13 13 13
Lavender oil GR4S 4 20 11 13
5 9 17 14
6 17 13 12
1 0.05 0.04
7 8 14 11
2 0.02 0.02
8 11 17 7
3 0.22 0.20
9 11 6 8
4 0.23 0.2I
10 6 5 5
5 0.23 0.21
6 0.09 0.08 Total 108 105 95
7 0.04 0.03
8 0.01 001
9 - 0.05 - 004 Mean days 4.5 4.8 4.5
10 - 0.01 - 0.01 SD 2.4 2.2 2.3

since a reduction of this magnitude occurred in 80% of
the cases.
Some cases had to be excluded from this secondary
analysis because measurements were recorded on two
few days, or a discomfort score on day I was zero. This
accounted for I3 cases. There were a further 66 cases
where discomfort scores failed to fall to 50% of their
initial value. These include nine with one measurement
missing and one with two missing. The remaining cases
were examined to determine whether those cases which
did not achieve a 50% reduction in discomfort scores
were unevenly distributed between groups. The result is
shown in Table 7, and there is no significant difference
between groups.
The data were then analysed to determine whether this
was a difference in the mean time to reach a 50%
reduction in discomfort scores in the cases where this did
occur. Care was taken in making this calculation over the
cases where the day 1 value was missing; for such cases
the day 2 value was taken as the baseline. The results are
summarized in Table 8.
The difference between the means is not significant
using a one-way analysis of variance (F0.58).
Side-effe d s
No side-effects were identified by the women or mid-
wives during the trial. Those using the additives smelling
of lavender made gratuitous comments indicating the
substances were pleasurable to use. This was less so for
those using the control (GRAS)additive.
DISCUSSION
The current surge in interest in aromatherapy may create
a climate in which new practices may be introduced

95
A. Dale and S. Cornwell
without adequate critical appraisal. This study has exam-
ined the practice of adding six drops of pure lavender oil
to bath water daily for 10 days after childbirth to reduce
perineal discomfort.
The study provides no evidence to support the prac-
tice as it stands. However, comments collected show that
most mothers using the oil found it a pleasant experience.
There seem to be few, if any, previous systematic
studies which evaluate the clinical use of lavender oil (or
other oils used in aromatherapy) against a control. It is
difficult, therefore, to place the results of this study in any
context. We would suggest that further research is
therefore required.
In particular, further research may confirm or refute the
results of this study, and could valuably explore the effect
of varying the amount of oil used as an additive and/or
the mode of application.
Acknowledgements
The authors would like to thank the midwifery staff in
Huntingdon Health Authority for their co-operation in
this study, and the consultant obstetric staff for their
support. Without such co-operation the study would
have been difficult to complete. We are grateful, too, to
D r George Dodd of the Olfactory Research Unit at
Warwick University for his specialized support and the
preparation of the additive in his laboratory. W e are also
indebted to Paul Smith, principal statistician at the East
Anglian Regional Health Authority for this advice and
help in analysing the data. Thanks are also due to Clive
Harries in the Research and Development Department of
technical support, and to Jenny Martin for her unflagging
secretarial services.
Finally we must acknowledge the grant from the East
Anglian Regional Health Authority’s Locally Organized
Research Committee which made the work possible.
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