Effects of Aromatherapy on Patient Satisfaction With Surgical Abortion at Less Than 10 Weeks Gestation
Phase: NA
Conditions: Surgical Abortion, Patient Satisfaction, Anesthesia, Pain
Sponsor: University of Colorado, Denver

Protocol Template 
Page 1 
CF-146, Effective 7/10/11 
 
w 
COMIRB Protocol 
COLORADO MULTIPLE INSTITUTIONAL REVIEW BOARD 
CAMPUS BOX F-490    TELEPHONE:  303-724-1055  Fax:  303-724-0990 
 
 
 
Protocol #:  
21-2561 
Project Title:    Effects of Aromatherapy on Patient Satisfaction with Surgical Abortion at Less than 
10 weeks gestation: A Randomized Controlled Trial 
 
 
 
Principal Investigator:  Rebecca Cohen, MD  
Version Date: 10/26/2022 
 
 
 
 
 
  
 
I. Hypotheses and Specific Aims: 
 
A. Overall Research Question: Does lavender aromatherapy increase patient satisfaction  
during surgical abortion at less than 10 weeks gestational age?  
 
B. Null Hypothesis: Among women undergoing surgical abortion prior to 10 weeks 0 days 
gestational age, there is no difference in patient satisfaction measured using the ISAS 
between those randomized to lavender aromatherapy or to placebo.  
 
C. Primary Objective: To compare women’s satisfaction with their abortion experience 
as measured on the Iowa Satisfaction with Anesthesia Scale (ISAS) following a 
surgical abortion less than 10 weeks 0 days gestational age between women 
randomized to lavender aromatherapy versus placebo. Our hypothesis is that women 
receiving lavender aromatherapy will report higher satisfaction scores as compared to 
women receiving placebo.  
 
D. Secondary Objectives:  
1. To examine if baseline state and trait anxiety are mediating factors between use of 
aromatherapy and patient satisfaction.  
2. To evaluate differences in patient satisfaction in those who receive oral sedation 
compared to those who receive no sedation, in patients receiving lavender 
aromatherapy and placebo.  
3. To compare maximum procedural pain measured by Visual Analog Scale (VAS) in 
patients receiving lavender aromatherapy and placebo.  
4. To measure patient acceptability of lavender aromatherapy as a complementary 
and alternative medicine used during first trimester surgical abortion through a 
post- procedure survey.  
II. Background and Significance:  
A. Project Summary.  
We propose a single-site, double-blinded, placebo-controlled clinical trial of lavender 
aromatherapy versus placebo for patient satisfaction in adult women having a surgical 
abortion before 10 weeks and 0 days gestation. We will evaluate whether lavender 
aromatherapy is an effective adjunct therapy for patient satisfaction during first trimester 
surgical abortion. We will measure satisfaction using the Iowa Satisfaction with Anesthesia 
Scale (ISAS). We hypothesize that women receiving lavender aromatherapy will report 
higher satisfaction scores compared to women receiving placebo.  
Prior studies have investigated the use of aromatherapy in laboring patients, in 
menstruating women, and in general post-operative populations. No investigations have 

Protocol Template 
Page 2 
CF-146, Effective 7/10/11 
 
focused on the use of lavender aromatherapy as an adjunct therapy to paracervical block 
and/or oral narcotics and anxiolytics in outpatient surgical abortion. Our study is novel in 
investigating patient satisfaction with first trimester surgical abortion using lavender 
aromatherapy.  
The contribution of this proposed research to the literature is significant because current 
affordable anesthetic adjuncts to opioids and benzodiazepines are limited.  
B. Background  
In 2016, 80% of abortions occurred within the first ten weeks of gestation.
1 The majority of 
aspiration procedures occur in outpatient settings with premedication including a 
paracervical block and a non-steroidal anti-inflammatory drug.
2 Patients commonly report 
moderately severe pain that is not decreased with oral narcotic medications.
3 Patients 
have a great deal of interest in non- pharmacologic adjuncts that might reduce pain or 
anxiety, or improve the overall patient experience. A previous study showed auricular 
acupuncture reduced pain and anxiety; however, another study evaluating patient choice of 
ambient music, physical contact, narration, meditation, or focused breathing did not find 
that these interventions reduced pain scores.
4-6  
Anxiety may affect the vulnerability and experience of patients who present for first 
trimester surgical abortion and moreover, may be predictive of a patient’s response to 
aromatherapy as a complementary and alternative medicine (CAM). Trait anxiety is a more 
stable, lasting, individual patient characteristic in people who have a tendency to view 
situations as more stressful or dangerous, whereas state anxiety is a temporary negative 
emotion and feeling of apprehensiveness or tension experienced during a threatening 
situation.
7 The stronger the anxiety trait, the more likely a person is to experience 
elevations in state anxiety.  
Aromatherapy-use of essential oils, derived from plants, absorbed through the skin or 
olfactory system-can affect the body in three ways: pharmacologically through effects on 
hormones and enzymes, psychologically through relaxing and sedating effects, and 
physiologically through the brain’s response to inhaling aromas
8-10. Olfactory stimulation 
related to aromatherapy can reduce pain, specifically nociceptive and acute pain, and 
change physiologic parameters such as pulse, blood pressure, and skin temperature
9,11.  
The analgesic effect is one lavender’s most studied properties.
12 Lavender has been used 
as a treatment for anxiety and mood disorders, as a sedative, spasmolytic, 
antihypertensive, antimicrobial, antifungal, and antiseptic.
13-14  
Obstetric and gynecologic pain has garnered the most attention when examining the 
efficacy of aromatherapy as an isolated therapeutic intervention.
11 Lavender essential oil 
aromatherapy significantly decreases the severity and length of menstruation pain, and 
also decreases pain intensity and increases satisfaction in laboring patients.
15-18 Although 
aromatherapy is widely used as a CAM adjunct, currently little is known about its 
effectiveness as an adjunct therapy for abortion.
8,19 
III. Preliminary Studies/Progress Report:  None 
 
 

Protocol Template 
Page 3 
CF-146, Effective 7/10/11 
 
 
IV. Research Methods 
 
A.  Outcome Measure(s):   
Satisfaction will be assessed using the ISAS, a validated patient-experience centered 
measurement tool.
20-22 This survey was designed to specifically assess participant 
satisfaction with anesthetic care. The self-reported questionnaire consists of 11 question 
items such as “I hurt,” “I felt safe,” “I had nausea,” each assessed on a Likert-type scale 
ranging from “Disagree very much” to “Agree very much.” The responses are then scored 
from -3 to +3 and summed for a total possible score of -33 to +33 and then an average 
score can be obtained. This instrument has been validated in multiple studies, including 
prior abortion studies at this institution (Thaxton and Pitotti, manuscript in preparation). 
Maximum procedural pain will be assessed using an unmarked 100mm VAS scale, with 
anchors at 0mm (left) being “no pain” and 100mm (right) being “pain as bad as it could be.”  
Based on variance findings from the NOVIA (Nitrous Oxide versus IV Sedation for 
Anesthesia study, we performed a sample size calculation with an alpha level of 0.05 and a 
beta of 0.83 in order to detect a 0.5U difference in the mean ISAS score between controls 
and patients receiving lavender aromatherapy. 
 
B. Description of Population to be Enrolled:   
i. Eligibility Criteria  
Eligibility criteria include women who have decided to have an outpatient abortion and are 
at least 18 years of age, with a viable intrauterine pregnancy with gestational age less 10 
weeks 0 days as determined by ultrasound crown rump length. The pregnancy viability 
criteria was included due to the stress, sadness and grief surrounding pregnancy loss that 
may affect the magnitude of difference of the exposure on the outcome of patient 
satisfaction. The less than 10 weeks 0 days gestational age limit was decided based on 1.) 
The majority of abortions occur at less than 10 weeks gestational age 2.) No cervical 
preparation is required and our surgical practice after this gestational age generally 
changes from manual to electric suction.  
ii. Exclusion Criteria  
Exclusion criteria include women with contraindications or allergies to ibuprofen, lidocaine, 
or jojoba oil, with non-viable intrauterine pregnancy or pregnancy greater than or equal to 
10 weeks gestational age. This study will not recruit adults who are unable to consent or 
who are currently incarcerated.  
iii. Number of Subjects and Statistical Power  
Based on variance findings from the NOVIA (Nitrous Oxide versus IV Sedation for 
Anesthesia) study, we performed a sample size calculation with an alpha level of 0.05 and 
a beta of 0.83 in order to detect a 0.5U difference in the mean ISAS score between 
controls and patients receiving lavender aromatherapy. This sample size calculation 
resulted in a sample size of 200 participants (100 receiving lavender and 100 receiving 
placebo). We will enroll up to 220 participants to account for a 10% drop-out rate.  

Protocol Template 
Page 4 
CF-146, Effective 7/10/11 
 
We will perform a secondary analysis to evaluate mean ISAS scores in patients who 
received oral sedation compared to those who did not receive oral sedation. Additionally, 
we will perform a secondary analysis to compare mean ISAS in patients with high and low 
state and trait anxiety scores.  
C. Study Design and Research Methods  
i. Research Design and General Methodological Approach  
We propose a single-site, double-blinded, placebo-controlled clinical trial of lavender 
aromatherapy versus inert oil placebo for patient satisfaction in adult women having a first 
trimester outpatient surgical abortion before 10 weeks and 0 days gestation. Our study will 
be conducted at the University of Colorado Comprehensive Women’s Health Center, a 
freestanding outpatient family planning clinic. All study endpoints will be collected on the 
date of procedure and thus no follow-up will be necessary. In order to be able to show that 
lavender aromatherapy is an effective adjunct to standard treatment, we will recruit 200 
women (100 to receive the intervention of lavender aromatherapy and 100 to receive a 
placebo).  
For purposes of masking, all patients enrolled in the study will be required to wear a cloth 
face covering over their nose and mouth during their procedure to minimize diffusion of the 
aromatic scent in the procedure room. All participants will receive standard pre-operative 
analgesia with 600mg Ibuprofen PO and local anesthetic with a standardized 20 cc cervical 
block (10cc of 1% lidocaine without epinephrine mixed with 10cc of 0.9% normal saline). 
The State-Trait Anxiety Inventory (STAI )and a pre-procedure patient survey will be filled 
out prior to the procedure. A visual analog scale (VAS) for maximum procedure pain will be 
filled out immediately after procedure completion (as defined as removal of the speculum). 
Lastly, the Iowa Satisfaction with Anesthesia Scale (ISAS) and a post-procedure patient 
survey will be administered 15 minutes after the completion of the procedure. Surgical 
abortion procedures will proceed per usual clinical practice.  
ii. Subject Recruitment and Allocation  
This study will be performed at the University of Colorado Women’s Comprehensive Health 
Center (CWHC) - a free-standing family planning clinic providing pregnancy termination 
services up to 22 weeks gestational age. Procedures at CWHC are performed by OBGYN 
residents, Complex Family Planning fellows, and faculty.  
Eligibility for participation will be determined by abortion clinic physician providers, all of 
whom are study team members,at initial encounter. Women presenting for abortion will be 
screened by clinic physician providers for eligibility based on chart review, dating 
ultrasound, and patient preference for pain control (IV anesthesia or no) following initial 
provider interview. If determined to be eligible for participation and interested, women will 
meet with trained research staff study team members who will explain the study as well as 
the risks and benefits of participation.  
CWHC performs approximately 20-25 surgical abortions less than 10 weeks 0 days 
gestational age without intravenous sedation each month . We assume 80% enrollment 
and a drop our rate of 10%. Based on this information, we approximate that recruitment will 
be completed in 12 months.  
  
D. Description, Risks and Justification of Procedures and Data Collection Tools: 

Protocol Template 
Page 5 
CF-146, Effective 7/10/11 
 
i. Admission Procedure  
Patients presenting for abortion procedure up to 10 weeks 0 days gestation will be screen 
by an abortion clinic physician provider, all of whom are study members, for eligibility 
criteria, only after medical chart has been reviewed, ultrasound has been performed, and 
participant has signed appropriate clinical consent forms for the surgical abortion 
procedure. If eligible, the woman will be approached for possible participation by a 
research assistant in a private clinic room. If interested and willing to participate, the patient 
will undergo consent for study enrollment. All participants determined to be eligible and 
approached will be documented per CONSORT guidelines.  
Following enrollment, participants will be instructed on how to self-administer the 
aromatherapy. Participants will fill out a pre-procedure survey with questions related to 
prior use and feelings regarding aromatherapy and other CAM techniques. Additionally, 
they will fill out the State-Trait Anxiety Inventory (STAI), which is a 40-item self-reported 
questionnaire to measure their current state of anxiety and anxiety proneness. The STAI 
takes approximately 10 minutes to complete. Pre-procedure temperature, pulse and blood 
pressure will be recorded.  
Study randomization to lavender aromatherapy or placebo will occur just prior to the 
initiation of the abortion procedure. A permutated block stratified randomization scheme 
will be utilized so that equal numbers of participants receiving no sedation and PO sedation 
will be randomized to lavender aromatherapy or placebo. 1cc of dilute lavender 
aromatherapy and placebo will be pre-filled in a 5/8 dram mini amber glass bottle provided 
to the patient. Immediately prior to procedure start (defined as after receiving antibiotic and 
emptying bladder), participants will be instructed to self-administer the study product. They 
will bring down their personal cloth mask to chin level and rub the study product within the 
amber glass bottle on their upper lip and nose (left and right ala, alarfacial grooves, and 
columella). Participants will be instructed to take 4 deep breaths and then replace their 
mask over their nose. The patient will then proceed to the procedure.  
The participant, providers, and research team will be blinded to the treatment allocation. 
The level of training of the physician performing the procedure will be documented (e.g. 
resident, fellow, attending). If the physician is at any point concerned about participant 
health or safety, treatment allocation will be revealed in order to provide optimal 
management. If allocation is unmasked to the treatment team, this will be recorded.  
Immediately after procedure completion, a VAS documenting maximum procedural pain 
will be completed. Women will be monitored for a minimum of 15 minutes after procedure 
completion. Post-procedure temperature, pulse and blood pressure will be recorded, and 
participants will receive written and verbal discharge instructions. At this point, participants 
will receive and complete the ISAS as well as a post-procedure survey with questions 
related to their experience using scented oils during their abortion procedure.  
After completion of all study materials, if the patient prefers to remove the study product, 
they will be provided a wet gauze upon request.  
ii. Follow-up Procedure  
All study endpoints will be collected on the date of the procedure. Patients will not be 
followed up after procedure unless clinically indicated.  
iii. Description of products to be used  

Protocol Template 
Page 6 
CF-146, Effective 7/10/11 
 
Lavandula angustifolia (English Lavender): A 10% dilute Lavandula angustifolia 
essential oil blend will be used in this study. Lavandula angustifolia was chosen based on 
the idea that the oil can promote relaxation and treat anxiety, nausea and menstrual 
cramps. To create the dilute essential oil blend, 60 drops of Lavandula angustifolia will be 
added to one fluid ounce (2 tablespoons/30mL) of jojoba carrier oil.  
Jojoba Oil (100% organic golden expeller-pressed Simmondsia chinensis): Jojoba oil 
is the liquid produced in the seed of Simmondsia chinensis (jojoba) plant shrub. Jojoba is a 
clear golden liquid wax at room temperature with a faint nutty aroma. Jojoba was chosen 
as a carrier oil because of its stark similarities to the natural occurring sebum of humans 
based on its wax esters and fatty acids.  
The anticipated risks of the use of the jojoba oil and Lavandula essential oil are: skin 
irritation and undesired intensity or characteristic of the scent. 
    
E. Potential Scientific Problems:   
i. Criteria for Discontinuation  
In order to ensure and prioritize optimal medical care, if an unanticipated reaction or 
intolerance to the study product is encountered during the procedure, the patient or 
provider can request immediate withdrawal of their face mask where upon a clinical staff 
member will provide a wet gauze to wash the upper lip and nose (left and right ala, 
alarfacial grooves, and columella). If a reaction or intolerance is encountered, this will be 
recorded along with the timing (prior to start of procedure, during the procedure, or after 
the procedure but prior to submitting all study documents). 
 
F.   Data Analysis Plan:   
i. Data Management  
Data will be entered into RedCap on the date of the procedure by research staff at CWHC. 
Research staff will have completed institutional review board training in RedCap prior to 
initiation of the study. Study packets will be stored in a secure file cabinet located in the 
clinic. These cabinets will be kept locked at all times. The study consents will be kept in the 
same room in a separate locked cabinet with a different key. Only IRB-approved study 
team members will have access to RedCap and participant materials. The list that links the 
participant information to the study identification number will kept separately and will be 
destroyed after data analysis is complete.  
ii. Data Analysis  
Satisfaction will be assessed using the ISAS, a validated patient-experience centered 
measurement tool.
20-22 This survey was designed to specifically assess participant 
satisfaction with anesthetic care. The self-reported questionnaire consists of 11 question 
items such as “I hurt,” “I felt safe,” “I had nausea,” each assessed on a Likert-type scale 
ranging from “Disagree very much” to “Agree very much.” The responses are then scored 
from -3 to +3 and summed for a total possible score of -33 to +33 and then an average 
score can be obtained. This instrument has been validated in multiple studies, including 
prior abortion studies at this institution (Thaxton and Pitotti, manuscript in preparation). 

Protocol Template 
Page 7 
CF-146, Effective 7/10/11 
 
Maximum procedural pain will be assessed using an unmarked 100mm VAS scale, with 
anchors at 0mm (left) being “no pain” and 100mm (right) being “pain as bad as it could be.”  
We will perform descriptive analyses for the demographic data collected in this study. ISAS 
scores will be averaged and comparison of means will be performed. Maximum procedural 
pain scores on the VAS will be compared using a Student’s t-test. We will assess patient 
acceptability by evaluating the results from the survey portion of this study using 
descriptive statistics and 95% confidence intervals for acceptability based on the survey 
data.  
A subgroup analysis of patient satisfaction will be performed according to participant 
preference for pain control (oral sedation or no sedation), as well as baseline 
characteristics such as anxiety (state and trait) and previous experience using CAM 
techniques.  
We will use a p-value of <0.05 as a cut-off for statistical significance.  
G.  Summarize Knowledge to be Gained:   
 
Currently, there are no known studies investigating the use of lavender aromatherapy in 
outpatient abortion procedures. Through this randomized, placebo-controlled trial, we 
expect to find that lavender aromatherapy will improve satisfaction with anesthesia, will be 
acceptable to patients, and will improve the overall patient experience for women 
undergoing first trimester surgical abortion. If effective in increasing satisfaction with 
minimal side-effects, aromatherapy could not only be a low-cost, complementary addition 
to current, standard pain management for first trimester abortion, but even more, it could 
also improve the overall abortion care experience for patients. Given current limited 
anesthesia options, aromatherapy could serve as an affordable and acceptable non-
narcotic, non-sedating adjunct to current standard of care during first trimester surgical 
abortion. Within a larger scope, our project represents a growth area in abortion research: 
patient-centered care. The impact of this project is to inform the practice of patient-
centered abortion care through evaluation of patient-experience centered outcomes; if 
effective, aromatherapy techniques could be instituted in any outpatient surgical abortion 
practice in an effort to provide care that is respective of, and responsive to patient 
preferences and needs.   
 
 
 H. References: 
 
1. Guttmacher Institute. “Induced Abortion in the United States,” May 3, 2016. 
https://www.guttmacher.org/fact-sheet/induced-abortion-united-states. 
2. O’Connell, Katharine, Heidi E. Jones, Melissa Simon, Vicki Saporta, Maureen Paul, E. 
Steve Lichtenberg, and National Abortion Federation Members. “First-Trimester Surgical 
Abortion Practices: A Survey of National Abortion Federation Members.” Contraception 79, 
no. 5 (May 2009): 385–92. https://doi.org/10.1016/j.contraception.2008.11.005. 
3. Micks, Elizabeth A., Alison B. Edelman, Regina Maria Renner, Rongwei Fu, William E. 
Lambert, Paula H. Bednarek, Mark D. Nichols, Ethan H. Beckley, and Jeffrey T. Jensen. 
“Hydrocodone-Acetaminophen for Pain Control in First-Trimester Surgical Abortion: A 
Randomized Controlled Trial.” Obstetrics and Gynecology 120, no. 5 (November 1, 2012): 
1060–69. https://doi.org/10.1097/AOG.0b013e31826c32f0. 

Protocol Template 
Page 8 
CF-146, Effective 7/10/11 
 
4. Ndubisi, Chioma, Antoinette Danvers, Melanie A. Gold, Lisa Morrow, and Carolyn L. 
Westhoff. “Auricular Acupuncture as an Adjunct for Pain Management during First 
Trimester Abortion: A Randomized, Double-Blinded, Three Arm Trial.” Contraception 99, 
no. 3 (2019): 143–47. https://doi.org/10.1016/j.contraception.2018.11.016. 
5. Tschann, Mary, Jennifer Salcedo, Reni Soon, and Bliss Kaneshiro. “Patient Choice of 
Adjunctive Nonpharmacologic Pain Management during First-Trimester Abortion: A 
Randomized Controlled Trial.” Contraception 98, no. 3 (September 1, 2018): 205–9. 
https://doi.org/10.1016/j.contraception.2018.05.007. 
6. Tschann, Mary, Jennifer Salcedo, and Bliss Kaneshiro. “Nonpharmaceutical Pain Control 
Adjuncts During First-Trimester Aspiration Abortion: A Review.” Journal of Midwifery & 
Women’s Health 61, no. 3 (2016): 331–38. https://doi.org/10.1111/jmwh.12445.  
7. Wiedemann K. Anxiety and Anxiety Disorders. In: Smelser NJ, Baltes PB, eds. 
International Encyclopedia of the Social & Behavioral Sciences. Pergamon; 2001:560-
567. doi:10.1016/B0-08-043076-7/03760-8 
8. Boehm, Katja, Arndt Büssing, and Thomas Ostermann. “Aromatherapy as an Adjuvant 
Treatment in Cancer Care — A Descriptive Systematic Review.” African Journal of 
Traditional, Complementary, and Alternative Medicines 9, no. 4 (July 1, 2012): 503–18. 
9. Shin, Byung-Cheul, and Myeong Soo Lee. “Effects of Aromatherapy Acupressure on 
Hemiplegic Shoulder Pain and Motor Power in Stroke Patients: A Pilot Study.” Journal of 
Alternative and Complementary Medicine (New York, N.Y.) 13, no. 2 (March 2007): 247–
51. https://doi.org/10.1089/acm.2006.6189. 
10. Trevelyan, Joanna E., and Brian Booth. Complementary Medicine for Nurses, Midwives 
and Health Visitors. Basingstoke: Macmillan, 1994. 
11. Lakhan, Shaheen E., Heather Sheafer, and Deborah Tepper. “The Effectiveness of 
Aromatherapy in Reducing Pain: A Systematic Review and Meta-Analysis.” Pain Research 
and Treatment 2016 (2016): 1–13. https://doi.org/10.1155/2016/8158693. 
12. Denner, Sallie Stoltz. “Lavandula Angustifolia Miller: English Lavender.” Holistic Nursing 
Practice 23, no. 1 (January 2009): 57–64. 
https://doi.org/10.1097/01.HNP.0000343210.56710.fc. 
13. Sasannejad, Payam, Morteza Saeedi, Ali Shoeibi, Ali Gorji, Maryam Abbasi, and Mohsen 
Foroughipour. “Lavender Essential Oil in the Treatment of Migraine Headache: A Placebo-
Controlled Clinical Trial.” European Neurology 67, no. 5 (2012): 288–91. 
https://doi.org/10.1159/000335249. 
14. Cavanagh, H. M. A., and J. M. Wilkinson. “Biological Activities of Lavender Essential Oil.” 
Phytotherapy Research 16, no. 4 (June 2002): 301–8. https://doi.org/10.1002/ptr.1103. 
15. Ou, Ming-Chiu, Tsung-Fu Hsu, Andrew C. Lai, Yu-Ting Lin, and Chia-Ching Lin. “Pain 
Relief Assessment by Aromatic Essential Oil Massage on Outpatients with Primary 
Dysmenorrhea: A Randomized, Double-Blind Clinical Trial.” The Journal of Obstetrics and 
Gynaecology Research 38, no. 5 (May 2012): 817–22. https://doi.org/10.1111/j.1447-
0756.2011.01802.x. 

Protocol Template 
Page 9 
CF-146, Effective 7/10/11 
 
16. Lee, Myeong Soo, Hye Won Lee, Mohamed Khalil, Hyun Suk Lim, and Hyun-Ja Lim. 
“Aromatherapy for Managing Pain in Primary Dysmenorrhea: A Systematic Review of 
Randomized Placebo-Controlled Trials.” Journal of Clinical Medicine 7, no. 11 (November 
10, 2018). https://doi.org/10.3390/jcm7110434. 
17. Kaviani, Maasumeh, Sara Azima, Narges Alavi, and Mohammad Hossein Tabaei. “The 
Effect of Lavender Aromatherapy on Pain Perception and Intrapartum Outcome in 
Primiparous Women.” British Journal of Midwifery 22, no. 2 (February 2014): 125–28. 
https://doi.org/10.12968/bjom.2014.22.2.125. 
18. Tanvisut, Rajavadi, Kuntharee Traisrisilp, and Theera Tongsong. “Efficacy of 
Aromatherapy for Reducing Pain during Labor: A Randomized Controlled Trial.” Archives 
of Gynecology and Obstetrics 297, no. 5 (May 2018): 1145–50. 
https://doi.org/10.1007/s00404-018-4700-1. 
19. Upchurch, Dawn M., and Laura Chyu. “Use of Complementary and Alternative Medicine 
among American Women.” Women’s Health Issues 15, no. 1 (January 2005): 5–13. 
https://doi.org/10.1016/j.whi.2004.08.010. 
20. “Dexter - 2012 - Iowa Satisfaction with Anesthesia Scale.Pdf.” Accessed August 24, 2020. 
https://www.franklindexter.net/PDF%20Files/IowaSatisfactionAnesthesiaScale.pdf. 
21. Dexter, Franklin. “Iowa Satisfaction with Anesthesia Scale.” Korean Journal of 
Anesthesiology 62, no. 3 (2012): 297. https://doi.org/10.4097/kjae.2012.62.3.297. 
22. Dexter, Franklin, John Aker, and Will A. Wright. “Development of a Measure of Patient 
Satisfaction with Monitored Anesthesia Care: The Iowa Satisfaction with Anesthesia 
Scale.” Anesthesiology 87, no. 4 (October 1997): 865–73. 
https://doi.org/10.1097/00000542-199710000-00021.