**1. Introduction**

During childbirth, fear and anxiety go hand in hand with anticipation and joy [1]. Indeed, childbirth is a stressful and physically painful event in a woman's life, to the point that labor pain has been defined as one of the most severe types of human pain [2]. Perception of pain during labor is due to uterus' contractions, uterine extension, and cervical dilation [3]. Inadequate pain management may affect diverse outcomes, such as psychological health, sexual functioning, or the infant–mother bond [4]. Previous studies stressed the association between pain and anxiety [5]. Anxiety activates the sympathetic nervous system releasing stress-related hormones (e.g., cortisol and adrenaline), which, as a consequence, may increase the severity of labor pain [6]. Therefore, it is imperative for midwives and obstetricians/gynecologists (Ob/Gyns) to find effective ways to relieve labor pain and anxiety.

Non-pharmacological methods such as relaxation techniques, massage, acupuncture, and aromatherapy are considered nowadays a promising area in midwifery thanks to their ease of use, low cost, and effectiveness [1,7–10]. Among them, aromatherapy represents one of the most used non-pharmacological methods for women in labor. It refers to the

Cutillo, S.; Zapparella, R.; Statti, G.; Maldonato, N.M.; Locci, M.; Bochicchio, V. The Effectiveness of Neroli Essential Oil in Relieving Anxiety and Perceived Pain in Women during Labor: A Randomized Controlled Trial. *Healthcare* **2022**, *10*, 366. https:// doi.org/10.3390/healthcare10020366

**Citation:** Scandurra, C.; Mezzalira, S.;

Academic Editors: Manoj Sharma and Kavita Batra

Received: 20 January 2022 Accepted: 11 February 2022 Published: 14 February 2022

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**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

employment of the power of plant-sourced essential oils to treat and heal the individual's body and psyche [11], and represents a strategy of care that utilizes essentials oils by massaging them into the skin, adding them to bath water, or inhaling their odor when added to a steam infusion [12].

Aromatherapy has been used to enhance women's well-being during post-partum, as well as to facilitate mother–infant interactions [13]. It is often referred to as a useful means to alleviate anxiety and pain, thus fostering the individuals' well-being [14]. Furthermore, aromatherapy has been shown to decrease anxiety and perceived pain during labor [15], as well as increase comfort and satisfaction [14,16]. Aromatherapy has been also successfully utilized jointly with massage to decrease stress and enhance immune function during pregnancy [12], as well as to reduce body tension and emotional stress [17].

Even though aromatherapy and essential oils such as orange scent, geranium, and lavender have been employed to reduce anxiety and perceived pain during labor [1,18–20], no studies have been carried out utilizing neroli oil to alleviate pain and anxiety during childbirth.

Neroli oil is extracted from the *Citrus aurantium* L. blossoms, commonly named bitter orange, which is a tree belonging to the *Rutaceae* family. It has antimicrobial and antioxidant properties [21], and has been shown to possess active constituents that play a significant role against inflammation, thus resulting useful for pain management [22]. Other therapeutic properties include sedative, calming, tonic, cytophylactic, aphrodisiac, anti-depressant, and antispasmodic action [23]. Most importantly, neroli oil can be utilized as an anxiolytic [24]. Therefore, neroli oil is frequently used for medicinal purposed, in particular for treating gastrointestinal disorders, tachycardia, and rheumatism, for minimizing central nervous system disorders [25], and as a sedative [26]. *Citrus Aurantium L.* flowers produce the orange blossom water, also utilized for therapeutic purposes [27]. Originally employed as a cardiac stimulant, for carminative purposes, and to help babies fall asleep, this water has been suggested to be useful in detoxification programs or when quitting addiction habits such as smoking [23]. Besides the aromatic water, the distillation of sour orange flowers produces neroli, a rare aromatic oil that contains a fragrance and represents the core of one of the world's most used perfumes, "eau de cologne," which is also used in pharmacy as a flavoring agent [21], as well as in some medicines approved by the American Food and Drug Administration.

Based on these premises, this study aimed at determining the effect of neroli oil aromatherapy on anxiety and pain intensity perception in a group of women in labor.
