Mohammadi A, Mohammad-Alizadeh-Charandabi S, Mirghafourvand M, Javadzadeh Y, Fardiazar Z, Effati-Daryani F. Effects of cinnamon on perineal pain and healing of episiotomy: a randomized placebo-controlled trial. J Integr Med. 2014;12(4):359-366.
Episiotomy, a common obstetric intervention during which an incision is made to enlarge the vaginal opening during childbirth, is often accompanied by perineal pain in the immediate postpartum period that can affect child care and other responsibilities. Episiotomy treatments include nonsteroidal anti-inflammatory drugs for pain and Betadine® (Purdue Pharma L.P.; Stamford, Connecticut) for wound healing (although Betadine is no longer used frequently in the United States for postnatal perineal care). For some women, those therapies are unsatisfactory; instead, they seek more effective, safer options. Cinnamon (Cinnamomum spp., Lauraceae) bark’s essential oil and ethanolic extract preparations exhibit numerous beneficial properties, including anti-inflammatory, antioxidant, and antimicrobial activities1; however, no human studies have been conducted on its analgesic and healing effects. These authors conducted a randomized, double-blind, placebo-controlled trial to determine the effects of a cinnamon extract ointment on episiotomy wounds.
Women aged 18 to 40 years who had given birth vaginally with episiotomy were recruited in Tabriz, Iran, at two hospitals affiliated with Tabriz University of Medical Sciences (Alzahra and Taleghani Hospitals) and at one hospital affiliated with the Iranian Social Security Organization. In these hospitals, 90% of women undergo episiotomies during their first vaginal delivery and 70% during their second and third deliveries. (One reviewer of this article noted that such high percentages of women undergoing episiotomies in these hospitals represents “irresponsible and outdated medical care.” In 2005, episiotomies for vaginal births were performed on only 30 to 35% of women in the United States.2) The authors recruited 144 patients (mean age: 26.4 ± 4.9 years) from February 20, 2013 to October 31, 2013; follow-up ended on November 11, 2013. While in the hospital, the patients completed a questionnaire on socio-demographic and reproductive characteristics. Each patient’s episiotomy incision was measured, and a baseline of perineal pain and wound healing was assessed.
The authors randomly assigned 72 patients to the cinnamon ointment group or the placebo group, both of which were similar in terms of socio-demographic and reproductive characteristics. For more than half of the women in each group, the delivery was their first. The patients were instructed on how to apply the ointment to the episiotomy wound twice daily every 12 hours for 10 days.
The hydroalcoholic cinnamon bark extract ointment (2% by weight; prepared at the Industrial Pharmacy Laboratory at the Tabriz University of Medical Sciences) contained cinnamon, methyl paraben, propyl paraben, and Eucerin® (a dermatological cream for dryness, itching, etc.; Beiersdorf AG; Hamburg, Germany). Prepared at the same laboratory and placed in tubes identical in color, shape, and size, the placebo ointment contained the same ingredients except for the cinnamon extract.
For pain relief, 10 mefenamic acid capsules (400 mg) were administered to each patient. The patients were given a diary to record ointment use, analgesics taken, and any adverse side effects, and they were instructed to return to the hospital with their empty ointment tubes after 10 to 11 days for reassessment.
Primary outcomes were assessed as follows: Perineal pain was measured by visual analogue scale (VAS) and recorded at baseline (one hour after episiotomy repair), four (±1), and eight (±1) hours after the first treatment with the ointment, and at 10 to 11 days after delivery. Wound healing was assessed at baseline, eight (±1) hours after first applying the ointment, and at 10 to 11 days after delivery by using the Redness, Edema, Ecchymosis, Discharge, Approximation (REEDA) scale. Secondary outcomes included components of REEDA, the number of analgesics taken during the trial, the resumption of normal daily activities within five days postpartum, and adverse side effects. At 10 to 11 days postpartum, 62 patients in the cinnamon group and 61 in the placebo group remained in the trial for final analysis.
At baseline, the mean pain intensity was 5.0 ± 1.8 in the cinnamon group and 4.6 ± 2.0 in the placebo group. Pain intensity in the cinnamon group was significantly lower than in the placebo group after four hours (mean difference [MD]: -0.6; 95% confidence interval [CI]: -1.0 to -0.2); after eight hours (MD: -0.9; CI: -1.4 to -0.3); and after 10 to 11 days (MD: -1.4; CI: -2.0 to -0.7). Compared with baseline values, pain intensity reduced by 16% at four hours, by 26% at eight hours, and by 76% at days 10-11 in the cinnamon group; the placebo group had pain intensity reductions of 2% at four hours, 4% at eight hours, and 43% at days 10-11. REEDA healing scores were significantly lower in the cinnamon group than in the control group at eight hours (MD: -0.2; CI: -0.4 to -0.04) and at days 10-11 after delivery (MD: -1.6; CI: -2.0 to -1.1). Compared with baseline, REEDA scores were 53% lower in the cinnamon group and 6% lower in the placebo group at days 10-11. Overall, both pain intensity and healing scores were significantly lower after cinnamon ointment intervention compared with placebo ointment intervention (P<0.01).
Evaluation of secondary outcomes revealed no significant between-group differences in the REEDA components at baseline and after eight hours, except for improved scores for wound approximation in the cinnamon group (P=0.02). Compared with baseline scores, wound healing scores in the cinnamon group improved significantly more than in the placebo group in four of five components (P<0.01 for redness and edema, P=0.021 for ecchymosis, and P=0.003 for approximation). At days 10-11 postpartum, no significant between-group differences were noted in the number of mefenamic acid capsules or other analgesics taken.
The number of patients resuming their normal daily activities within five days postpartum was significantly higher (P=0.003) in the cinnamon group (46 women; 74%) than in the placebo group (29 women; 48%). No adverse side effects were reported in either group.
Cinnamon bark’s three main compounds are eugenol, cinnamaldehyde, and linalool. According to the authors, eugenol, which has a topical numbing effect, may affect inflammation by reducing prostaglandin biosynthesis. Cinnamaldehyde also has anti-inflammatory properties,3 and linalool possesses analgesic and anti-inflammatory properties that work by reducing nitric oxide and activating analgesic paths of cholinergic and glutamatergic compounds.4,5 The cinnamon polyphenols may also reduce inflammation.6
The authors conclude: “Our study results showed that use of cinnamon ointment on episiotomy incision for 10 d[ays] reduced intensity of perineal pain and improved healing of the incision with no significant side effects.”
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- Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA. 2005;293(17):2141-2148.
- Zarifkar A, Skandaryan HMS, Mokhtary M, Ay J. An evaluation on antinociceptive effects of eugenol by formalin test in rats. [Persian with abstract in English.] J Dental Medicine. 2003;16(1):61-67.
- Peana AT, Marzocco S, Popolo A, Pinto A. (–)-Linalool inhibits in vitro NO formation: probable involvement in the antinociceptive activity of this monoterpene compound. Life Sci. 2006;78(7):719-723.
- Peana AT, D’Aquila PS, Chessa ML, Moretti MD, Serra G, Pippia P. (–)-Linalool produces antinociception in two experimental models of pain. Eur J Pharmacol. 2003;460(1):37-41.
- Hong JW, Yang GE, Kim YB, Eom SH, Lew JH, Kang H. Anti-inflammatory activity of Cinnamon water extract in vivo and in vitro LPS-induced models. BMC Complement Altern Med. 2012;12:237. doi: 10.1186/1472-6882-12-237.