Journal of Obstetrics and Gynaecology, 2014; Early Online: 1–4
© 2014 Informa UK, Ltd.
ISSN 0144-3615 print/ISSN 1364-6893 online
DOI: 10.3109/01443615.2014.970522
ORIGINAL ARTICLE
Lavender-thymol as a new topical aromatherapy preparation
for episiotomy: A randomised clinical trial
T. Marzouk1, R. Barakat2, A. Ragab2, F. Badria3 & A. Badawy2
1Department of Maternity and Gynecology of Nursing, Faculty of Nursing, Mansoura University, Egypt, 2Department of Obstetrics and
Gynecology, Faculty of Medicine, Mansoura University, Egypt, and 3Department of Pharmacognosy and Medicinal Plants, Faculty
of Pharmacy, Mansoura University, Egypt
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The objective of this study was to evaluate the effectiveness of
topical lavender-thymol in promoting episiotomy healing. This
placebo-controlled, single-blinded, randomised clinical trial
involved 60 primiparous women. REEDA score was used to evaluate
the outcome of the trial. On the 7th post-partum day, women in
Placebo-treated group had worse Redness, Edema, Ecchymosis,
Discharge and Approximation (REEDA) score of 3.93 ⴞ 3.65
compared with those in Lavender-thymol-treated group (2.03 ⴞ 1.7)
with significant difference (P ⴝ 0.013). Visual analogue Scale (VAS)
score for pain at episiotomy in Lavender-thymol-treated group
was 3.5 ⴞ 1.9, whereas in Placebo-treated group it was 2.1 ⴞ 2.2
For personal use only.
(p ⴝ 0.011) for dyschezia, 3.8 ⴞ 1.7 and 2.8 ⴞ 1.6 in Placebo- and
Lavender-thymol-treated women, respectively (p ⴝ 0.023). At
7th post-partum week, dyspareunia was more severe in Placebo-
treated group compared with that in Lavender-thymol-treated
group (5.3 ⴞ 2.7 vs 2.7 ⴞ 1.5 and p ⬍ 0.001). Topical aromatherapy
using lavender-thymol was highly effective, suitable and safe
for episiotomy wound care with little or no expected side effects
compared with that using placebo.
Keywords: Aromatherapy, episiotomy, lavender-thymol, pain
Introduction
Episiotomy is an obstetric incision of the perineum done at the
crowning time to widen the vaginal orifice, thereby facilitating
vaginal birth and preventing obstetric perineal lacerations (Thorp
and Bowes 1989; Cunningham et al. 2005). Episiotomy healing is
a composite process that can take 4–6 weeks depending on the
size of the incision and the type of the material used to close the
incision (Noronha 2004).
The perineal muscles are involved in many actions like sitting,
walking, stooping, squatting, coitus, urination and defaecation;
that is why an incision in this area causes a great deal of uneasi-
ness. Perineal pain is a common consequence after episiotomy,
affecting up to 42% of women 10 days after delivery and persisting
in 10% at 18 months (Caroli et al. 19984). Also, 58% of women
experience superficial dyspareunia 3 months after delivery
(Barratt et al. 1999). Pain at episiotomy site is related to swelling
and inflammation that can be managed by topical application of
ice pack or dry heat; cleansing with squeeze bottle; and using a
cleansing shower, tub bath or sitz bath. Also, topical application of
antiseptic or anaesthetic ointment or spray is commonly used as
Correspondence: Ahmed Badawy, MD, FRCOG, PhD, Professor of OB/GYN, Department of Obstetrics and Gynecology, Faculty of Medicine, Mansoura
University, Egypt. Tel: 0020502268830. Fax: 0020502268840. E-mail. ambadawy@yahoo.com
a pharmacologic intervention for perineal pain (AAP and ACOG
2002).
Alternative and complementary therapies such as essential oils
in aromatherapy have been used to enhance episiotomy healing
and to endorse patient’s comfort (Burns et al. 2000; Hunt et al.
2004; Cavangah and Wilkinson 2002). Lavender oil is one of
the aromatherapy essential oils which have a variety of therapeu-
tic and curative properties, including anti-bacterial, anti-fungal,
sedative, anti-depressive properties and also effective for burns
and insect bites (Zahrani et al. 2002). Lavender has carminative
(smooth muscle relaxing), anti-flatulence and anti-colic proper-
ties in aromatherapy (Dale and Cornwell 1994). In this placebo-
controlled, single-blinded, randomised clinical trial, we aimed
at evaluating the clinical efficacy of a new formula of 2%
lavender-thymol oil (1:1 v/v) in jojoba carrier oil preparation used
for episiotomy healing in primiparous women.
Materials and methods
This single-blinded randomised clinical trial comprised
69 primiparous women among those who attended the labour
ward in the Department of the Obstetrics and Gynecology
in Mansoura University Hospitals, Egypt in the period from
February 2012 to April 2013. The study was approved by the
departmental ethics committee at Mansoura University Hospitals
and each participant gave a written consent before inclusion in
the trial. All women had singleton foetus presented in the vertex
at the time of delivery and had medio-lateral episiotomy and no
other vaginal or perineal tears occurred. All women with prema-
ture rupture of membranes for more than 24 hours, with allergy
to lavender-thymol, with medical or obstetric problems, with
duration of pregnancy of ⬍ 37 or ⬎ 42 weeks, and with prolonged
or precipitate labour were excluded from the study. Women who
complained of dyschezia, dyspareunia or vulvo-vaginitis before
labour as well as those with haematoma in the incision occurring
up to 12 post-partum hours were excluded from the study.
Preparation of lavender-thymol
Lavender flowers (Lavandula officinalis) were collected just
before blooming and were subjected to steam distillation and
dried over anhydrous sodium sulphate to produce 1.47% v/v of
lavender essential oil. The authenticity and identity of the obtained
lavender volatile oil was determined using GC–MS (Thermo
 2 T. Marzouk et al.

Scientific, Central lab, Mansoura University, Mansoura 35516, Results

Egypt). Thymol oil was obtained from Fluka-Aldrich (Poole,
A total of 60 primiparous women who had medio-lateral epi-
Dorset, UK). A therapeutic oil composition useful for external
siotomy during labour were legible for analysis. There were no
applications was obtained. It was created by mixing essential oils
statistically significant differences between both groups regarding
of 2% lavender-thymol oil (1:1 v/v) in jojoba oil as a carrier. The
patients’ characteristics (Table I).
volume of each added constituent can be modified according to
At the 7th post-partum day, the women in the Placebo-treated
the desired treatment, the percentage of chemical constituents in
group had worse total REEDA score (3.93 ⫾ 3.65) compared
each oil as well as the published data regarding the efficacy of such
with women in the Lavender-thymol-treated group (2.03 ⫾ 1.77).
combinations.
This difference was significant (95% CI, 0.4–3.4; p ⫽ 0.013) with
All incisions were repaired by the same operator under local
standardised effect size (Cohen’s d) of 0.7 (indicating that the
anaesthesia using white Vicryl 3/0 suture. All patients were
mean of Lavender-thymol-treated group is located at the 76th
randomised to treatment groups using computer-generated
percentile of the Placebo-treated group distribution).The REEDA
random table and sealed envelopes, and choosing the envelopes
score varied by items. Compared with those in Placebo-treated
was done by the chief nurse. The first group (Lavender-thy-
group, the women in the Lavender-thymol-treated group had less
mol-treated group) contained 65 women who were instructed
redness (0.53 ⫾ 0.9 vs 0.13 ⫾ 0.43, respectively; p ⫽ 0.032), less
to take care of the episiotomy site using a solution prepared
oedema (0.97 ⫾ 0.93 vs 0.47 ⫾ 0.78, respectively; p ⫽ 0.027) and
by adding 7 drops of previously prepared lavender-thymol to
less discharge (0.7 ⫾ 0.92 vs 0.2 ⫾ 0.61, respectively; p ⫽ 0.016)
4L of warm tap water. Cleaning the incision was done through
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(Table II).
directing the nozzle of the bottle towards the incision site twice
At the 7th post-partum day, the VAS pain at episiotomy site
daily for 7 days, and then drying the perineum from front to
for women in the Placebo-treated group was 3.5 ⫾ 1.9, whereas
back. The second group (Placebo-treated group) contained 64
for women in the Lavender-thymol-treated group it was 2.1 ⫾ 2.2
women, who followed the same instructions but using 250-ml
(p ⫽ 0.011). Mean VAS score for dyschezia was 3.8 ⫾ 1.7 and
squeeze bottle that contained a warm solution prepared by
2.8 ⫾ 1.6 in Placebo- and Lavender-thymol-treated groups,
adding 10ml of saline (0.9%) to 4L of warm tap water. Both the
respectively (p ⫽ 0.023). At the 7th post-partum week, dyspare-
investigators and the patients were blinded to the treatment
unia was more severe in women of Placebo-treated group as
solutions.
compared with those of Lavender-thymol-treated group
After randomisation, 9 women were excluded from the study:
(5.3 ⫾ 2.7 vs 2.7 ⫾ 1.5, respectively; p ⬍ 0.001). The current study
6 women refused follow-up visits and 3 women did not resume
also evaluated the analgesic consumption during the first three
coitus at 7th post-partum week. Thus, 60 patients remained (30
For personal use only.

post-episiotomy days and revealed significant difference between

women in each group) for analysis. All women in the study were
followed on 7th day and 7th week post-partum by home visit to
evaluate REEDA and Visual Analogue Scale (VAS) (Kindberg t al.
2008) scores for pain at episiotomy site and during intercourse.
All women were questioned about dyschezia and consumption of
analgesic during the first three post-partum days.
Statistical analysis
Sample size was calculated based on expected difference of 15%
between the two groups with targeted power of 80% and 95%
confidence interval (CI). Continuous variables were presented
as means ⫾ standard deviations (SDs). Categorical variables
were reported as number and proportions. Data were checked
for normality and equality of distribution, before performing
any analysis. Comparisons between Placebo-treated group and
lavender-thymol-treated group were made using independent
t-test for continuous normally distributed variables. Skewed
continuous variables were logarithmically transformed to attain a
normal distribution and then compared using independent t-test.
Chi-square test was used for comparison between categorical
variables. All calculations were performed using SPSS 17.0 soft-
ware for Windows. All analyses were 2-tailed. P values of ⬍ 0.05
were regarded as significant.
the two groups (Table III).
Discussion
Proper care of episiotomy incision is essential for promoting
it’s healing and preventing further complications. Nursing has
a vital role in counselling the post-natal women regarding self-
care of the perineum at home in order to attain proper healing
(Noronha 2004). The effectiveness of Betadine as an antiseptic
solution and the probability of impairing or even preventing
wound healing made it important to find an effective antiseptic
that can be used safely for episiotomy care (Cooper et al. 1991;
Zahrani et al. 2002). The clinical efficacy of a new formula of 2%
lavender-thymol oil (v/v) in jojoba carrier oil preparation was
assessed for episiotomy wound healing in primiparous Egyptian
women. All data showed a significant reduction in inflammation
level and pain compared with placebo, with no reported side
effects.
Our study reported clinical evidence on the influence of
essential oils in wound healing and their potential application in
clinical practice. It focuses mainly on the new natural prepara-
tion from lavender-thymol oils. This simple unique formula of

REEDA Scale.

Points Redness Oedema Ecchymosis Discharge Approximation

0 None None None None Closed

1 Within 0.25 cm of incision
bilaterally
2 Beyond 0.5 cm of incision
bilaterally
3 Beyond 0.5 cm of incision
bilaterally
Less than 1 cm from Within 0.25 cm bilaterally or
incision 0.5 cm unilaterally
1–2 cm from incision 0.25–1 cm bilaterally or
0.5–2cm unilaterally
Greater than 2 cm from Greater than 1 cm bilaterally or
incision 2 cm unilaterally
Serum Skin separation of 3 mm or less
Serosanguineous Skin and subcutaneous fat
separation
Bloody, purulent Skin and subcutaneous fat and
fascial separation
 A new topical aromatherapy preparation for episiotomy 3
Table I. Patients characteristics in Placebo-treated and Lavender-thymol-treated groups.

Placebo-treated Lavender-thymol-treated
group (n ⫽ 30) group (n ⫽ 30) P∗

Socio-demographic Data
Age (years) 25.6 ⫾ 3.8 24.2 ⫾ 4.2 0.193
Body mass index (Kg/m2) 28.8 ⫾ 2.5 29.1 ⫾ 3.1 0.750
Job experience %, (n) 56.7% (17) 50% (15) 0.796
Education level %, (n)
Preparatory school 10% (3) 13.3% (4) 0.748
Secondary school 40% (12) 36.7% (11)
University 50% (15) 46.7% (14)
Obstetric Data
Gestational age (weeks) 38.7 ⫾ 1.6 38.9 ⫾ 1.6 0.571
Duration of 2nd labour stage (minutes) 72.5 ⫾ 14.1 70.7 ⫾ 12.3 0.601
Duration of 3rd labour stage (minutes) 4.3 ⫾ 2.2 4.0 ⫾ 2.3 0.692
Length of episiotomy (cm) 4.0 ⫾ 0.8 3.9 ⫾ 1 0.436
Newborn parameters
Newborn weight (g) 3051.0 ⫾ 271.8 3026.7 ⫾ 211.2 0.692
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Head circumference (cm) 33.6 ⫾ 0.8 33.8 ⫾ 0.8 0.462

P∗ value is significant if ⬍ 0.05.

lavender-thymol oils rich in linalool (from lavender) and thy-
mol (from Thymus), at proper amounts, may exert a threefold
effect on episiotomy wound healing, anti-microbial effect and
pain relief. Furthermore, it also affects pH homoeostasis and
equilibrium of inorganic ions as it inhibits potassium-induced
increase in concentration in a dose-dependent manner like
channel blockers such as Verapamil (Adam 2000).
For personal use only.
coli, Pseudomonas aeruginosa, Bacillus subtilis, spoilage bac-
teria Brochothrix thermosphacta (or P. fluorescens), Serratia
liquefaciens, Lactobacillus curvatus and Lactobacillus sakei; and
moulds such as Rhizobium leguminosarum, Aspergillus niger, A.
flavus, A. ochraceus, Fusarium oxysporum and Penicillium spp
(Hodaib and Speroni 2002). Thymol oil incorporated in chitosan
has proved to exhibit wound healing effect (Mater 2010). More-

This study revealed that lavender-thymol mixture had better over, thymol oil proved to exhibit a wound healing effect in burn
total REEDA score than placebo. There is significantly reduced (Nurcan et al. 2003).
redness, oedema and discharge, while the difference in ecchy- Also, our findings revealed that using the new formula of
mosis and approximation was not significant between the two 2% lavender-thymol in jojoba carrier oil significantly reduce
groups. Such findings are consistent with the findings of Vakilian VAS score for three forms of pain including episiotomy site
et al., who reported a significant reduction in redness and pain, dyschezia and dyspareunia compared with using placebo.
inflammation in the Lavender group (Vakilian et al. 2010). These results are in accordance with the study of Sheikhan et al.
The chemical composition of both lavender and thymol is that investigated the analgesic effect of lavender oil essence on
paramount in its effect. Alpha-terpineol, terpinen-4-ol and perineal pain in 60 primiparous Iranian women with episiotomy,
camphor are the chemical constituents of lavender essential oil and showed a significant reduction in pain relief medications
that have anti-bacterial effects. Alpha-pinene, beta-pinene and in Lavender group (Sheikhan et al. 2011). Another study by
p-cymene are other substances that have anti-fungal activity Burns et al. recorded a reduction in pethidine consumption
(Lis-Balchin and Hart 1999; Gilani et al. 1998). Carvacrol, from 6% to 0.4% and reduction in pain scores in women using
terpinen-4-ol, linalool, sabinene and α-terpinene, which are in aromatherapy after childbirth (Burns et al. 2000). Reduction
Lavandula stoechas, are effective in some Gram-negative and
Gram-positive bacteria (Adam 2000; Aligiannis et al. 2001). The
anti-inflammatory effect of Lavandula stoechas can be related Table III. VAS and post-partum analgesic consumption in Placebo-treated
to the presence of caryophyllene oxide (Gorena et al. 2002). and Lavender-thymol-treated groups.
Thymol oil has a long history of use mainly as a preservative with
Placebo-treated Lavender-treated
bacteriostatic or bactericidal activity on several pathogens such group (n ⫽ 30) group (n ⫽ 30) P∗
as Staphylococcus aureus, Salmonella Typhimurium, Escherichia
VAS pain for
Episiotomy site on 7th 2.1 ⫾ 2.2 3.5 ⫾ 1.9 0.011
Table II. REEDA score on 7th post-partum day in Placebo-treated and post-partum day
Lavender-thymol-treated groups. Dyschezia on 7th 3.8 ⫾ 1.7 2.8 ⫾ 1.6 0.023
post-partum day
Placebo-treated Lavender-thymol-treated Dyspareunia on 7th 5.3 ⫾ 2.7 2.7 ⫾ 1.5 ⬍ 0.001
group (n ⫽ 30) group (n ⫽ 30) P∗ post-partum week
Post-partum analgesic consumption
Redness 0.53 ⫾ 0.9 0.13 ⫾ 0.43 0.032
During the 1st day 2.5 ⫾ 0.7 1.7 ⫾ 0.8 ⬍ 0.001
Oedema 0.97 ⫾ 0.93 0.47 ⫾ 0.78 0.027
(tablets)
Ecchymosis 1.1 ⫾ 1.21 0.8 ⫾ 1.18 0.337
During the 2nd day 1.7 ⫾ 0.7 1.2 ⫾ 0.7 0.003
Discharge 0.7 ⫾ 0.92 0.2 ⫾ 0.61 0.016
(tablets)
Approximation 0.63 ⫾ 1.03 0.43 ⫾ 0.77 0.400 During the 3rd day 1.1 ⫾ 1 0.6 ⫾ 0.7 0.018
Total score 3.93 ⫾ 3.65 2.03 ⫾ 1.77 0.013 (tablets)
P∗ value is significant if ⬍ 0.05. P∗ value is significant if ⬍ 0.05.
 4 T. Marzouk et al.
of VAS pain may be attributed to more than one effect: first,
the effect of essential oils on the limbic system that may lead to
release of encephalin, endorphin and serotonin (Habanananda
2004), and the sedative and anaesthetic effects of linalyl acetate
and linalool constituents of lavender (Sugawara et al. 1998; Kim
et al. 1991; Gheraldini et al. 1999). Balchin and Hart reported that
the sedative and anaesthetic effects of linalyl acetate and linalool
are related to their ability of increasing the local blood circulation
and reducing the muscle tone (Lis-Balchin et al.1999). Moreover,
thymol, the major component of Thymus vulgaris has sedative
and analgesic effects (Fernanda et al. 2012). Although, we did not
perform cost-effective formal analysis, lavender-thymol is a cheap
preparation when compared with all analgesics used in Egypt.
We had high dropout rate (n ⫽ 9) from both groups due to
long time interval between the two assessment points (7th day
and 7th week post-partum), and the far distance of patient’s
homes. These limitations made data collection a time-consuming
process. However, no single complaint was reported due to usage
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of this medication, but future randomised clinical trials with large
sample size and careful follow-up are suggested to confirm and
rationalise the obtained results. Also, the education curriculum
for nursing students and in-service training for staff nurses should
be revised and updated to be equipped with recent practices and
trends for episiotomy care.
To our knowledge, this is the first study that evaluated such
new combination of topical aromatherapy of 2% lavender-thymol
oils (1:1 v/v) in jojoba oil as a safe, efficient and economic therapy
for episiotomy wound care in Egypt. It showed that lavender-
thymol can be used as a simple, suitable and safe preparation
For personal use only.
for post-partum episiotomy wound care with little or no
expected side effects or local irritation affecting the patient’s
quality of life.
Declaration of interest: The authors report no declarations of
interest. The authors alone are responsible for the content and
writing of the paper.
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