“A COMPARATIVE CLINICAL STUDY TO EVALUATE THE …

“A COMPARATIVE CLINICAL STUDY TO EVALUATE THE EFFICACY OF

BHARANGYADI KALKA AND SHUDDHA HINGU IN THE MANAGEMENT

OF SUTIKA MAKKALLAW.R.T PUERPERAL AFTER PAINS”

BY

DR. BORADEVI HUNGUND B.A.M.S

DISSERTATION SUBMITTED TO

THE RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA,

BENGALURU

IN THE PARTIAL FULFILMENT FOR THE DEGREE OF

AYURVEDA DHANVANTARI

M.S. (PRASUTI TANTRA EVUM STREE ROGA)

Under the guidance of

DR. SHOBHA B. NADAGOUDA M.S (AYU)

Professor & HOD

Dept. of PG Studies in PTSR, S.V.M.A.M.C, IIkal

Department of Post Graduate studies in PTSR

Shri. VijayMahanteshAyurvedicMedicalCollege

IIKal -587125

2016-2018

RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES

KARNATAKA, BENGALURU

ABBREVATIONS

A.H. AshtangaHridaya

A.S.: AshtangaSangraha

Bhe.Sa: BhelaSamhita

Bha.Pr: Bhavaprakasha

B.R. BhaisajyaRatnavali

Cha.Sa: CharakaSamhita

C.D. Chakradatta

Chi : ChikitsaSthana

Dal : Dalhana

Ha.Sa. : HaritaSamhita

Ka.Sa: KashyapaSamhita

Ma.Kh : Madhyamakhanda

Ma. Ni: MadhavaNidana

Ni : NidanaSthana

Pu.kh PoorvaKhanda

Ut.Kh: Uttarakhanda

Sha.Sa : SharangdharaSamhita

Sha : ShareeraSthana

Su: Sutra Shthana

YR : Yogaratnakara

List of Tables

Table

No

Topic of the table Page No

1 Haematological Values in puerperium 27

2 Composition of colostrums and breast milk 32

3 Drugs of Bharangyadikalka 53

4 Drugs of ShuddhaHingu 53

5 Bharangyadi Kalka 60

6 Age distrubution in two groups studied 66

7 Eductiondistrubution in two groups studied 67

8 Occuptiondistrubution in two groups studied 68

9 Scoial status distrubution in two groups studied 69

10 Religion distrubution in two groups studied 70

11 Obstetric History distrubution in two groups studied 71

12 Diet distrubution in two groups studied 72

13 Prakrutidistrubution in two groups studied 73

14 UDARA SHOOLA. Assement in different time points of

patients in two groups studied

74



76

16 STANYA PRAVARTANA. Assement in different time points

of patients in two groups studied

77



79

18 INVOLUTION OF UTERUS Assement in different time points


80



82

20 LOCHIA. Assement in different time points of patients in two

groups studied

83


groups studied

85

List of Graphs

Table

No

Topic of the Graphs Page No

1 Age distrubution in two groups studied 66

2 Eductiondistrubution in two groups studied 67

3 Occuptiondistrubution in two groups studied 68

4 Scoial status distrubution in two groups studied 69

5 Religion distrubution in two groups studied 70

6 Obstetric History distrubution in two groups studied 71

7 Diet distrubution in two groups studied 72

8 Prakrutidistrubution in two groups studied 73



75



76



78



79



81



82


groups studied

84


groups studied

85

Abstract

A comparative clinical study to evaluate the efficacy of Bharangyadi kalka and Shuddha hingu in the management of Sutika Makkalla w.r.t puerperal after pains

ABSTRACT

Title:-“A Comparative clinical study to evaluate the efficacy of Bharangyadi Kalka

And Shuddha Hingu in the management of Sutika Makkalla W.R.T Puerperal After

Pains”

Sutika Makkalla, the post delivery complication frequently occurring in

women, is assocatied with accumulation of blood in the uterus due to various reasons.

The drugs Bharangyadi Kalka and Shuddha Hingu is used for the treatment of this

condition.The drugs Bharangyadi Kalka and Shuddha Hingu are having properties

like garbhashaya shodhaka, sula prasamana, rakta shodhaka, vatakapha hara, vedana

sthapana, anulomanan, deepana, pacana, stanya shodhaka, shotha hara etc. The same

are the desired effects of the study .

INTRODUCTION

Post delivery complication of Sutika Makkalla have been described in Sushrut Sharir

Adhyay 10(1).

After delivery the blood doesnot flow out but returns due to dhatukshinata,

vayu prakropa, dryness of the body or due to non availability of drugs required for

shodhan done after delivery or retains in the uterus after delivery due to obstructed

pathway.

This results in uterus getting streched due to haematoma causing, severe,

discomfort, pain below umbilical and bladder region, abdomen and cardiac region. At

times the pain is so severe that a pricking sensation with possibility of tearing of

bowel or its perforation. These are associated with flatulence and retention of urine.

This condition is generally referred to as the Makkalla, some times this accumulated

blood gets infected with virus and abscess can also formed.

Treatment of Sutika Makkalla by use of Bharangyadi Kalka and Shudha

Hingu is described in Ashtanga Samgraha 3 chapter 34-35 and in yogaratnakar

Sutikaroaga adhikara Makkalla Chikitsa Sholka No. 8 respectively.

Ayurveda describes these drugs used having Vedanastapana Garbhashaya

Shodhana, Sulaparsama, Rakta shodhna, Vatahara Anulomana etc., due to these

properties the drugs are used in this study

Abstract

A comparative clinical study to evaluate the efficacy of Bharangyadi kalka and Shuddha hingu in the management of Sutika Makkalla w.r.t puerperal after pains

MATERIALS & METHODS

The dry powders of Bharangi, Nagara, Devadaru was collected from local

markets whereas Hingu was collected from local area.

Prepartion of Kalka

All the drugs in dry powder were sieved through cotton cloth and fine powder

was obtained and Kalka was prepared as per classics freshly and given to the patient

whereas Hingu was made into powder form after frying it in ghee and was

administered to the patient with warm water.

SELECTION OF PATIENT

30 patient of Makkalla was selected for study from among the IPD of PTSR,

patient having undergone normal deliveries was considered for the trial with different

age groups, parity avoiding the patient with C.Section, assisted deliveries,

hypertension, D.M, PPH etc.,

Selected patient were divided into 2 groups of 15 patient each. Group A

patients were given Bharangyadi Kallka 6 grams bd for 5 days on empty stomach and

15 patients were administered shudha Hingu with ghee 125 mg X 5 days

RESULTS AND DISSCUCION

The given drugs in both groups showed good result in the pain parameter with

Shuddha Hingu showing better results as compared to Bharangyadi Kalka.

There was no significant results in the other parameter included in the study

but also no undue complications was seen in the study period.

Both the drug groups showed good improvement in increasing the bala of the

sutika thus favoured other parameters as may be physiological and can be advised in

sutika for the said parameter.

Key words : Sutika, Makkalla, Bharanagaydi kalka, shudha Hingu, After pains

Introduction

A comparative clinical study to evaluate the efficacy of Bharangyadi kalka and Shuddha Hingu in the management of Sutika Makkalla w.r.t Puerperal after pains. Page 1

INTRODUCTION

Ayurveda the science of life which exists since the creation of life has also

given due consideration about the specific epochs of women life. The phase of

pregnancy and child birth is not as simple and easy as it seems. The different

avastha like garibhini avastha, sutika avastha etc., have been clearly mentioned in

our classics by our acharyas.

In Ayurveda the women after delivery is called as Sutika6. The sutika avastha

(puerperium) has got certain time period which varies accordingly to different

authors, Sutika Paricharya and diseases which occur in sutika and its management

have been mentioned in our Ayurvedic texts12

.Pathya apathya aahara taken during

puerperium ends up with many complications, one among them is sutika makkalla.

and it is well explained in our classics.

If the women whose body becomes dry after delivery and is not treated with

teekshna dravya, the vata in the uterus obstructs the flow of blood causing makkalla.

Sutika avastha in Ayurveda can be compared to puerperium in Modern science

is the period of reverting back the pregnant state to non-pregnant state8.

According to modern science, puerperium after pains is the infrequent

spasmodic pain felt in the lower abdomen after delivery for a variable period of 4-5

days. Presence of blood clots or bits of the after birth leads to hypertonic contraction

of the uterus in an attempt to expel it out8.Prevalance rate – 40 to 50% of normal

delivery.

After pains are those pians when the body works hard to get recovered by the

presence of uterine contractions serve the important functions of clamping of open

blood vessels at the placenta site, minimizing the loss of blood after birth.

To overcome the frequent post partum morbidity and its association and

adverse perinatal out come and also to promote a healthy puerperium i.e. maternal

health so as to resume her normal activities as soon as possible, so the management

of sutika is essential to avoid causalties, occurrence of infections and various

disorders prone to in the period.

Introduction


In such painful condition, even after giving analgesics and antispasmodics,

the pain may not subside. So to see the effect of the mentioned drugs, as those drugs

are cost effective. With this view the clinical study entitled

“A CLINICAL STUDY TO EVALUATE THE EFFICACY OF

BHARANGYADI KALKA AND SHUDDHA HINGU IN SUTIKA

MAKKALLA.”

Objectives


OBJECTIVES OF STUDY

1] To study and understand Sutika makkalla sula in detail with Ayurvedic and

modern references.

2] To evaluate the efficacy of Bharangyadi kalka in sutika makkalla.

3] To evaluate the efficacy of Shuddha Hingu in sutika makkalla.

4] To study comparative efficacy of Bharangyadi kalka and

Shuddha Hingu in sutika makkalla.

Review of Literature


HISTORICAL REVIEW

The ancient medical system of India which dates back has explored all branches

of present existing medical science in the form of Astangas.

First documentation regarding Sutika was seen in the Samhita Kala

Vedic period

Entire vedic literature is full of ideas and facts relating to prasoothi tantra and

stree roga which guided the development of the subjects in post vedic era.

Samhita Kala

First and foremost complete documentation regarding sutika was seen in

Samhita Kala. Description regarding Suthika paribhasha, Kala, Paricharya and vyadhi

is available in all the Grantha of Bruhatrayee and laghutrayee.

Sushruta Samhita 1

Explanation regarding the Nidana, Lakshana and chikitsa of sutika Makkalla is

dealt in Sharira Sthana 10th

chapter

Charaka Samhita 62

An elaborate explanation of Suthikagara, Sutika Kala, Parichaya, Nidana,

Kricha Sadhyatwa of suthika roga is available in sharira sthana.

Astanga Sangraha 2

In sharira stana, 3rd chapter the symptoms of Makkalla sula and chikitsa is

described

Madhava Nidana of Madhavkara 4

There is mention of Nidana and Lakshana of Makkalla Sula .

Bhavprakash 9

In chikitsa sthana chapter 70 there is mention about Nidana, Samprati and

lakshana of Makkalla sula .



Yogaratnakar10

In stree Roga Adhikar chikitsa sthana, the chikitsa of Makkalla sula with

shuddha Hingu is mentioned, and description regarding sutika is available

Kashyapa samhita 12

Elaborate explanation of Sutika paricharya according to desha and jaati is

found, a list of suthika vyadhi are also explained with treatment

History of puerperium

In olden days the power of women was considered in the form of Goddess and

lady was considered as Bearer or nurturer.

In the middle ages however the child was given paramount importance. Thus

in threatening condition the life of the child was favoured, which led to high rate of

maternal mortality

The only disease condition explained in detail was the puerperial fever which

was much talked about during the end of 18th

century

Puerperial care and after pains were mentioned in all the recent obstetric text

books.



Review of Previous work :-

1] Dr. Sachan [Mrs.] Mamta – Role of Yavashara in sutika Makkalla .

Banaras Hindu University

(BHU) Varanasi.1990.

2] Dr.Surekha J. Dewaikar – Prevention of Sutika Makkalla by oral administration of Katu

Nimba Kwatha, Govt. Ayurved College,Nanded.India-2004

3] Dr.Vijaylaxmi G.Inamdar– A Comparative Clinical Study of Yavashara and

Shuddha Hingu in Sutika Makkalla.

Shri Kalabyreshwara Ayurvedic Medical College &

Research Centre, Bangalore- 2014.



SUTIKA

Nirukthi 24,25

* - -

- -

-

A womenwho has been just/recently delivered .

Paribhasha

- ११/६

The word soothika is coined to a woman, who has just given birth to a baby and after

apara patana. The process of Labour is said to be completed only after the expulsion

of placenta.26

- १

Vagbhata also has explained suthika paricharya only to be started after the expulsion

of garbha and apara20.

Hence after the delivery of child till the placenta is not expelled

the lady cannot be called as suthika.



Suthika Kala

All acharyas, except charaka have given a definite duration for period of

suthika.

- १०/१६

- ( १/१००,१०१)

Accoding to sushruta 19

and vagbhata 20

time period of soothika is said to be

one and half month or until the reappearance of her menstrual cycle.

Four months period of soothika kala is explained for soothika after the

extraction of mudha garbha (obstructed labour).21

-( ११)

Acharya kashyapa26,

Bhavaprakasha 30

and yogarathnakara 64

have explained

one month period of specific dietic management and still kashyapa specially confirms

that suthika kala is for 6 months.

Sutika roga

The woman become deprived by the increase demand on her by growing fetus

and placenta all the dhatus are in sluggish condition due to stress and strain of

pregnancy and delivery and due to rakta and kleda nisruti. Also there is agni dhatu



and bala ksahya hence the disease developing during sutika are said to be asadhya or

krichrasadhya.28

Kashyapa has described sutika rogas at two places 35 diseases in dushprajata

chikitsa adhyaya and 64 diseases in sootikopakramaniya adhyaya. Among 99

diseases, 25 diseases have been enumerated at both the places thus in total 74

different varities of sutika rogas have been mentioned.

Diseases mentioned in dushprajata chikitsa adhyaya27

Asragdhara Manyasthamb Vicharchika Vataasthila

Moha Sula Sotha Ardhasiroruja

Kitibh Dadru Yonidosha Yonibheda

Visphota Pama Prastashool Yonisopha

Hrud rog Plihodara Katisula Yoni vedana

Kamala Sakhavata Hrutsula Visarpa

Jwara Hanugraha Adhmana Chardi

Atisara Akshiroga Mutrarodha

Pravahika Vatagulma Kampa.



Diseases mentioned in suthikopakramaniya adhyaya26

Yonibhramsa Yoniksata Yonisrava Yoniprasupata

Parswashoola Visuchika Mahodara Makkala

Angamarda Praksepaka Apatanaka Vidradi

Pralapa Mutrasanga Unmada Daurbalya

Bhrama Karsya Bhaktadwsha Avipaka

Trsna Hikka Swasa Kasa

Pandu Raktagulma Anaha Mukharog

Yonibheda Yonispoha Yonivedana Prshtasula

Katisula Hridshoola Plihodara Shaakhavata

Haugraha Mayastamba Shopha Kamala

Jwara Atisara Visarpa Chardi

Pravahika Adhmana Mutrarodha Malarodha

Akshirog Kampa Vatashitla Vatagulma

Vicarchika Pratishyaya Galagraha Rajayakshma

Ardita Karnasrava Prajagarana Usnavata

Grahabadha Stanarog Rohini Raktapitta



Diseases mentioned at both places :29

Yonivedana Yonishopa Yonibheda

Prastaula Katisula Hridusla

Plihodara Sakhavata Hanugraha

Manyastambha Sotha Kamala

Jwara Atisarav Visarpa

Chardi Pravahika Adhmana

Mutrarodha Malarodha Akshiroga

Kampa Vaatasthila Vaatagulma

Vicharchika.

Apart from all these disease, Acharya Susruta and Vagbhata, given a detailed

description regarding makkalla shula which is commonly seen during sutika avastha

caused by vitiation of vata and retained blood in the uterine cavity. Also the

commonly seen sutika rogas are angamarda, prusta shula, yoni shula, gurugatrata etc

Causes of sutika roga27

Roaming out at night, terror, sudden fall from height, jealousy, grief, fear,

anger, day sleeping, suppression of various natural urges, excess eating before the

digestion of previous food and even in indigestion etc are some of the main causes of

all the sutika roga.



Line of treatment in sutika roga :30,31

Aggravated vata is the main culprit for causing disease, Hence the measure to

subside the vata are to be undertaken and also advised to take bala vardhak dravyas to

over come the tiredness which is due to labour process.

The best line of treatment is to avoid nidana ie nidana parivarjana. She should

be advised to use jeevaniya, brumhaniya, madhura and vatahara dravyas for the

purpose of abhyanga, parisheka, avagaha, utsadana etc in the form of ghrita, taila or

kwatha .

SUTHIKA PARICHARYA

Birth which is a natural process represents the utmost important event that

makes a lady responsible for producing offsprings. The physiologic transition from

pregnancy to motherhood heralds an enormous change in each woman physically and

mentally. This fabulous phase of pregnancy and delivery is strenuous and tedious to

the lady. Inspite of that post delivery period itself needs adjustment of lady not only to

the infant needs but also to her own physiological and psychological variations.

The Suthika avastha is described in Ayurveda with a particular mode of life

for a stipulated period.

प्राप्ते प्रसव काले च भयमतु्पाध्यते यत: ।

अस्ममन्नेक: स्मथत: पादो भवदन्यो यमक्षये: ॥ - का.सं.स्ि.११/२

एव ंस्ह गभभवसृ्ि क्षस्पत स्िस्थल सवभ िरीर धात ुप्रवाहण वेदना

क्लेद रक्त स्नसतृ स्विषे िनू्य िरीराच्च पनुनभवी भवस्त ॥ - अ.सं.िा.३/३९



GENERAL INDICATIONS AND CONTRA INDICATIONS –

प्रसतूा स्हतमाहारं स्वहारं च समाचरेत ्।

व्यायाम ंमथैनुं क्रोधं िीतसेवां स्ववजभयेत ्।

सवभत: पररििुा मयाद ्स्मनग्ध पथ्या अल्पभोजनात ्।

मवदेाभ्यङ्गपरा स्नत्यं भवने्मासमतस्न्िता ॥

- भा.प्र.प.ू४

The prasutha stree should use hitakara ahara and vihara, avoid vyayama,

vyavaya, sheeta maruta sevana and krodha. When she becomes parishudha, continue

with snigdha, pathya alpa bhojana, abhyanga and sweda every day. 63

The Panchakarma procedures like Asthapana Basti, Nasya, Virechana, Sira

vyadhana, teekshna Sweda are also contraindicated in suthika.

IMPORTANCE OF DOING SUTHIKA PARICHARYA 19

स्मथ्याचारात ्ससू्तकाया यो व्यास्धरुपजायते ।

स कृछ्रसाध्यो असाध्यो वा भवदे ्अत्यपतपभणात ्॥

- स.ुिा.१०/१९

For proper naveekarana of suthika.the paricharya explained by our acharyas is must to

follow. Other wise improper regime in the form of excessive nourishing or more of

apatarpana procedures will make suthika easily suceptable for diseases. Kashyapa has

described nearly Thirtyfive types 27

and Sixtyfour types 26

of suthika rogas.

Twentyfive diseases are common29

at both the places, most of these are difficult to

treat or incurable. Suthika if she does ratri nirgamana, divaswapna, having earsha,

bhaya, shoka etc, manasika abhitapa, ajeerna, adhyashana etc is prone to get alt sort of

vikara27

. So Suthika paricharya is a part and parcel of every prasava.



SUTIKA MAKKALLA

प्रजातायाश्च नायाभ रूक्षिरीरायामतीक्ष्णरैस्विोस्धतं रकं्त वायनुा तद्दिेगतेनास्तसंरुिं

नाभरेध:पार्श्भयोर्भमतौ र्स्मतस्िरस्स वा ग्रस्न्थं करोस्त; ततश्च नास्भर्मत्यदुरिलूास्न

भवस्न्त, ससू्चस्भररव स्नमतुद्यते स्भद्यत ेदीयभत इव च पक्वािय:, समन्तादाध्मानमदुरे

मतू्रसङ्गश्च भवतीस्त मक्कल्ल - लक्षणम ्॥ - स.ुसं.िा १०/२२

Unexcreated or unpurified blood inspite of use of pungent drugs by puerperal

women having dry body gets localized by vayu in uterus or the excreted blood is

retained by vayu in uterus. This retained blood produces a glandular structure in any

site amongst infraumbilical region, flanks, bladder, bladder neck (hypogastric region).

Due to this there is severe pain in umbilical and bladder region, abdomen and cardiac

region as well as headache. In pakwashaya region there is severe pain as if needles are

being torn or perforated, flautence and retention of urine also occur1.

प्रजाताया ंचेद्वस्मतमधूोदरेष ुिलंू मक्कलाख्यं मयात्तत्र यवक्षारचणू ंसस्पभषा

सिुोष्णोदकेन वा स्परे्त् । वरणास्द ंवा सपञ्चकोलमलेाप्रतीवापम ्॥३४॥ - अ.सं.िा ३

If after delivery the women develops pain in the region of head of the bladder

and abdomen which is known as Makkalla, she should take any one of the above

combination of drugs,i.e. paste of bharngi, nagara, devadaru mixed with hot water2.

मक्कल्लारप्ये स्िरोर्स्मतकोष्ठिलेू........... - अ.रृ.िा.१/९२

According to Ashtang Hridaya pain in shira, basti and koshta is makkalla sula3.



वाय:ु प्रकुस्पत: कुयाभत्संरुध्य रुस्धरं च्यतुम ्।

सतूाया रृस्च्छरोर्स्मतिलंू मक्कल्लसंस्ितम ्॥२॥ - मा.स्न.६४

According to madhava Nidana, says that the accumulated blood causes pain

in Heart, Head, Bladder in prasuta stree is called Makkalla4.

वस्नताया: प्रसतूाया वातो रूक्षेण वस्िभत: ।

तीक्ष्णोष्णिोस्षतं रकं्त रुदध््वा ग्रस्न्थ ंकरोस्त स्ह ॥१३६॥

नाभ्यध:पार्श्भयोवभमतौ र्स्मतमधू्दभस्न चास्प वा ।

ततश्च नाभौ र्मतौ च भवचे्छूलं तथोदरे ॥१३७॥

भवते्पक्वाियाध्मानं मतू्रसङ्गश्च जायत े।

एतस्भ्दषस्ग्भरुस्दतं मक्कल्लामयलक्षणम ्॥१२८॥ - भा.म.७०

The vayu of prasuta vitiated due to ruksha dravyas and by intake of ushna,

tikshna dravyas the rakta which gets shoshna and unexcreted produces a glandular

structure below umbilicus, flanks, bladder, neck of bladder which produces pain in

umbilicus, abdomen bladder & flatulence and retention of urine also occur 9

.



PUERPERIUM

From latin language "Puerperium" word got originated or derived, which

means to bring forth (pario) a child (puer).32

It is the period of adjustment after child

birth when anatomical and physiological changes of conception are reversed to an

almost prepregnancy level 8.The pelvic organs returns to the non-gravid state, the

metabolic changes of pregnancy are reversed and lactation is established. This

postpartum period lasts from delivery of the placenta until 6 weeks after delivery. Of

course all maternal adaptations during pregnancy do not necessarily subside

completely by 6 weeks postpartum.38

Diseases stated specific to pregnancy and the

puerperium may occassionaly be life threatening. It is therefore necessary to consider

the interaction of the anatomical and physiological changes of the puerperium with

preexisting medical and surgical complication of the pregnancy.

For the purpose of proper management this period can be divided into an 33,8

1. Immediate Puerperium

2. Early Puerperium

3. Remote Puerperium

Immediate Puerperium - It includes the first 24 hours after delivery, the stage of

acute post partum period.

Early Puerperium - It is the period of first week after delivery.



Remote Puerperium - It starts from second week to six weeks post-delivery.

Following delivery, when the endocrine influences of the placenta are removed, the

physiological changes of pregnancy are reversed and the body tissues, especially

pelvic organs, return to their previous state.

POSTPARTUM CHANGES8,34,35,36,37

Changes in Uterus

Involution of the Uterus

Immediately after delivery the uterus is hard, very much reduced in size &

fundus is generally felt 10-12 cm above symphsis pubis. During puerperium, the

uterus gradually decreases in size & by the 10-12 days it can no longer felt by

abdominal palpation. This process is known as "Involution’.

The uterus increased markedly in size & wt. during pregnancy, but involutes

rapidly after delivery. Estrogen, Progesterone & the chronic stretching of muscles

induced by enlarging fetus exert synergistic effect on the synthesis of actomyosin &

collagen. Soon after the delivery the involution process is started. Involution is the

rapid reduction in the size of the uterus and its return to a condition similar to its

prepregnant state. Involution of the uterus begins immediately after the expulsion of

the placenta. Three physiologic processes are involved in uterine involution, Uterine

contractions, Autolysis and Regeneration.

Progesterone as a result of the delivery autolysis triggers the release of

proteolytic enzymes and the migration of macrophages in to the endometrium this



action causes the protein to be broken into components that are excreted in the urine.

Autolysis represents a reduction of cell size rather than cell number. Following

delivery, the epithelium must regenerate and replace the uterine lining.

Immediately following delivery the uterus weighs about 1 kg & its size

approximately that of 20 weeks. At the end of the 1st week it normally will decrease to

the size of 12 weeks to be just palpable at the symphysis pubic. Myometrial

contractions or after pains assist in involution.These contractions occur during the

first 2-3 days of post partum and produce more discomfort in multiparous than in

primi. Such pains are accentuated during the nursing as a result of oxytocin release

from posterior pituitary, during 1st 12 hrs of post partum uterine contraction are

regular, strong and coordinated the intensity frequency and regularity of

contraction decrease after the 1st postpartum day as involution changes proceed uterus

involution is nearly completed by 6weks at which time the organ weighs less than 100

gms. The increase in number of cells are permanent to some degree so as the uterus is

following delivery of placenta there is immediate contraction of the placental size to a

size less than ½ the diameter of the original placenta. This contraction causes

constriction and permits occlusion of underlying blood vessels. It also accomplishes

haemostasis and presumably leads to endometrial necrosis. Initially placental site is

elevated and somewhat ragged and friable in appearance. Involution occurs by means

of the extension and down growth of marginal endometrium & by endometrial

regeneration is completed by the end of the post partum week, except at the placental

site, where the regeneration is usually complete uptill 6 wks.



Assessment of involution of uterus

Involution is assessed by daily measurement of the fundal height in relation to

the pubic symphsis. It is measured carefully at same time daily by the same person the

bladder is emptied beforehand & preferably the bowel too the uterus is to be

centralized. It is measured in two ways which are as follows.

1. Height from the symphsis pubis measured in cms

Just after delivery,the fundus lies above 13.5cms from the symphasis pubis.

The level remains same for 24hrs thereafter, there is steady decrease in height by

1.25cms in 24 hrs.so that by the end of second week ,the uterus become a pelvic organ

.the rate of involution thereafter slows down until by 6 weeks,the uterus becomes

almost normal in size.

2. From umbilicus, downwards in finger breadth.

1-2 days after delivery fundus is at the level of umbilicus.

3rd

day- 1- 2 finger below the umbilicus.

4th

day-2-3 finger below the umbilicus.

5th

day- midway between the umbilicus and superior margin of the symphysis pubis.

6th

day-1 finger below the fifth day

7th

day-3 finger above the symphysis pubis.

8th

day- 2 finger above the symphisis pubis.

10th

-12th

day-below the superior margin of symphysis pubis.



Abnormalities of involution

The normal process of involution may be affected adversely by many factor.

Two such abnormalities are,

1 sub involution

2 super involution

Sub involution:

When the involution is impaired or retarded, it is called subinvolution.

Causes;

Predisposing factors- Grand multipara

Anaemia and malnutrition

Uterine fibroid

Prolapse of the uterus

Retroversion of the uterus

Maternal ill health

Mismanagement of the third stage of labour

Aggravating factors 1. Retained product of conception.

2. Uterine sepsis.

Symptoms;

1. Abnormal lochial discharge either excessive or prolonged.

2. Irregular cramp like pain.

3. Rise of temperature.



Signs;

1. The uterine height is greater than the normal for the particular day on

Puerperium.

2. It feels boggy and softer.

3. Presence of features responsible for subinvolution may be evident.

Management

Appropriate therapy is to be instituted only when subinvolution is found to be

mere sign of some local pathology.

1. Antibiotics in sepsis.

2. Exploration of uterus in retained products.

3. Pessary in prolapsed or retroversion.

2. Super-involution;

The involution of uterus may be prolonged in women who are lactating, it is

called superinvolution. The uterus, however returns to normal size if the lactation is

withheld

Lochia 8,36,38

It is the discharge, which escapes from the genital tract during the first 3 to 4

weeks of puerperium. It is the discharge that originates from the uterine, cervix &

vagina.



It consists of sloughed decidua.Odour & reaction- healthy lochia has got

sweetish odour, and some explains that ,it has peculiar offensive fishy smell. It is

alkaline tending to become acid towards the end.

Lochia Rubra: This occurs for 1 to 4 days. It is red in colour and consists of blood,

fetal membranes, deciduas, vernix caseosa, epithelial cells, bacteria and meconium.

Lochia Serosa: It is yellowish initially, then brownish in colour and lasts for next 5 to

9 days. It consists of fewer RBCs more leucocytes, wound exudates, mucus from the

cervix and micro organisms (anerobic streptococci and staphylococci), the presence of

bacteria is not pathogenic unless associated with clinical signs.

Lochia Alba: This is white in colour and lasts for 10 to 15 days after lochia serosa

has disappeared. It consists of plenty of decidual cells, leucocytes, mucus, cholestrin

crystals, granular epithelial cells and micro organisms.

During the first 5 to 6 days the amount secreted is 250 ml, It is excessive in

deliveries following multiple gestation, hydramnios and big babies. It is scanty in

preterm deliveries.

Changes in The Cervix -36,38

After delivery, the cervical epithelium becomes very flaccid and thinner in the

first 4 days, the outer cervical margin, which corresponds to the external os, is usually

lacerated, especially laterally. The cervical opening contracts slowly, and for a few

days immediately after labour it readily admits two fingers. By the end of the first

week it has narrowed, hence the cervix thickens and the canal reforms.

At the completion of involution, however, the external os does not resume its

prepregnant appearance completely. It remains wider, with bilateral depressions at the



site of lacerations and remains as permanent changes that characterize the parous

cervix. The cervical epithelium undergoes considerable remodeling; this complete re-

epithelisation takes 6- 12 weeks.

Vagina-38

The over distended vagina, slowly returns to its prepartum shape around 3 rd

week. The reverting process is completed within 4-8 weeks. The tone of the vagina

never returns back to virginal state. The increased venous congestion makes the

mucosa delicate in this period. Even the vaginal rugasities reappear partially, introitus

remains permanently larger than virginal state. The lacerated, fibrosed healing hymen

represents in the form of carunculae myrtiformes.

Fallopian Tubes and Ovarian Functions 38

After delivery the low level of estrogen and progesterone will effect the

increased number of tall nonciliated cells in the fallopian tubes. Their nuclei will

extrude out, thickness of the cellular layer decreases, inflammatory changes are also

seen.

Elevated prolactin levels are the basis of anovulation in lactating mothers. As

the ovarian activity is suppressed, the resumption of menstruation may be delayed for

many months. Other wise in non-lactating mother, ovulation can occur as early as 70-

75 days postpartum with the resumption of menstrual period after 7-9 weeks.

Pelvic Changes8,37,38

For easy passage of the fetus, even pelvic cavity increases in its width, the

widening of the symphysis pubis and sacro-iliac joints are well observed. After



delivery the voluntary muscles of the pelvis and other pelvic supports slowly regain

their tone. Involution of muscles takes up-to 6-7 weeks, hence exercises should be

postponed till these stretched muscles come to their original state.

Systemic Changes –

Cardio Vascular System- 37,38,39

Just after parturition, plasma volume decreases due to bleeding. Hematocrit

values increases by 5% and cardiac out put increases by 50%. Pulse rate is increased

on the lsiday. On the 3

rd day post delivery there is a shift from extracellular fluid into

the vascular compartment causing 900 to 1,200ml increase in intravascular volume.

There is also slight increase in blood pressure in the first 5 days of puerperium.

Ventricular hypertrophy of pregnancy resolves in about one year.

Within 8 weeks after delivery the red cells volume returns to normal. The

rapid loss of blood during delivery stimulates reticulocytosis (which is maximum at

the 4th

postpartum day) and a moderate increase in the erythropoitin level during the

first week after delivery. There is hyper activity of bone marrow during puerperium,

prolactin also stimulates bone marrow. Due to stress of labour there is marked

leucocytosis, consisting especially of granulocytes.

Respiratory System -38

The oxygen consumption is increased during pregnancy and even in 7- 14

days after delivery. The delivery of child has decreased the uterine size hence the

diaphragm comes down. The volume of lungs will increase which reduces the

respiratory alkylosis and metabolic acidosis. The hypoapnea will also reduce.

Decreasing level of Progesterone is also responsible for the increased PCO2 in first



week postpartum. The oxygen saturation is increased to 95% during day one after

delivery.

Urinary System36,37,38,39

During labour, the sustained trauma to the nerve plexus will make the bladder

insensitive to raised intravesicular pressure. The changes which occur in urinary tract

during pregnancy disappear in a similar manner as the involutional changes. The

bladder mucosa become oedematus. enlarged with increased capacity of urine. The

over distended bladder with incomplete emptying leads to significant amount of

residual urine. Within 2-3 weeks the hydroureter and caliceal dilation of pregnancy is

much less evident.

Diuresis occurs to get rid of excess of extracellular fluid accumulated during

pregnancy. Even there is mild proteinuria in immediate postpartum period which is

normal. And Pregnancy induced glycosuria disappears. Increased Glomerular

Filtration Rate comes to normal by 8 weeks of puerperium and there is 25% increase

in renal plasma flow.

Metabolic Changes38

Fatty acids (Total and non esterified) return to the prepregnancy level on the

second post partum day. Plasma Triglyceride levels slowly fall to normal by 6-7

weeks. Lactation does not affect the fatty acid levels. Blood sugar level falls below

the pregnancy level on the 2nd

and 3rd

day after delivery due to an elevated renal

threshold. Free plasma amino acids increase post-partum on 2nd

or 3rd

day.



Hemodynamic Re-adjustment36,38

Delivery leads to obliteration or low resistence of uteroplacental circulation

and result in 10-15% reduction in the size of the maternal vascular bed. Loss of

placental endocrine function also removes a stimulus to vaso dilatation. This

reduction of blood volume and venous tone which becomes normal with a significant

decrease in deep vein size and increase in uterine vascular resistance. There is

increase in venous blood flow velocity in lower limbs.

A declining in blood volume with a rise in hematocrit is usually seen with in

3-5 days after delivery. Hemoconcentration occurs if the loss of red cells is less than

the reduction in vascular capacity. Hemodilution takes place in woman who loses

20% or more of their circulatory blood volume at delivery.



Table No -1 Hematological Values in Puerperium

Total Blood Volume

Decreases immediately Post Partum due

to blood loss at delivery

Plasma volume

Decreases immediately Post Partum due


Increases 3 days Post Partum due to shift

of extra cellular fluid into vessels

RBCs

RBC production returns to normal levels

RBC count returns to normal by 8 weeks

PP

Hb & Hct

Immediate decrease in Hb immediately

PP due


Hb levels stabilize by 2-3 days

HCT remains relatively stable

immediateiy after delivery

Hct returns to non-pregnant levels 4-6

weeks

WBCs

Decrease to 6- 10,000 after high of 25-

30,000 during intrapartum and immediate

postpartum returns to normal 4-7 days

Platelets

Increases at 3-4 days

Gradually returns to non-pregnant levels

Coagulation factors Increase in fibrolytic activity in first few

hours

Slow decrease to non-pregnant levels by

1-4 weeks

Slow decrease in coagulation factors by

1-4 weeks



Coagulation Mechanism 36,37

A sudden reduction in the platelet count is seen immediately after the placenta

has separated, but a secondary raise can occur later with an increase in their

adhesiveness.

During the 1st day after delivery the plasma fibrinogen concentration starts

decreasing and the lowest level is reached. After that a secondary increase in its level

occurs which is maintained till the second week after parturition, after which a down

ward trend again starts for the next 7 to 10 days.

These changes make the delivered women susceptible to thrombosis during

the puerperium. How ever a sharp return of normal fibrinolytic activity after delivery

does prevent this complication.

The clotting factors increased during pregnancy are used to provide a reserve

to compensate for their rapid utilization during delivery and also to achieve

haemostasis after delivery. A large deposition of fibrin occurs in the placental bed

after the delivery of the placenta. Thus there is a continous release of fibrin

breakdown products from the placental site.

Weight Loss8,36,38

Approximately 10-13 kg weight is gained during pregnancy. There is an

immediate loss of about 5-6 kg due to delivery of the infant, placenta, amniotic fluid

and blood loss. At the end of 6 weeks most of the mothers have lost of excess 4-5 kg

weight due to excretion of fluids and electrolytes.At least 2 liters of fluid is lost within

the first week and 1.5 liters in next 5 weeks after delivery.



Factors that influence increased puerperial weight loss includes weight gain

during pregnancy, primi parity, early return to work. Of course breast feeding or

maternal age won't affect weight loss.

Hormonal Changes38

Placental hormone levels decline very fast following delivery.

Human Placental Lactogen (HPL)

This has a half life of 20 min. No HPL can be seen in the maternal blood on

the lst day after delivery.

Human Chorionic Gonadotrophin (hCG)

This has a half life of 9 hrs. 48 to 96 hrs after delivery the levels are below

1000 mu/ml and 7 day post partum they are less than 100 mu/ml. It virtually

disappears by the 11 - 16th

day after delivery.

Plasma 17 B Estradiol

The level falls to 10% of pregnancy value within 3 hours of the 3rd

stage of

labour. By one week after delivery its lower level is achieved. Follicular phase level

(>50 pg/ml) is reached earliest by 19 to 21 days after parturition in non-lactating

women and by 60 to 80 days in lactating women. In latter, during the period of

lactational amenorrhoea the estrogen levels are less than lOpg/ml. Breast

engorgement that occurs 3-4 day after delivery is due to low estrogen levels (because

high estrogen levels suppress lactation)

Progesterone

This has very short half life (in minutes) hence by 3rd

post partum day, the

levels are far less than 1 ng/ml (luteal phase level).



Prolactin (PRL)

During pregnancy prolactin level rises up to 200ng/ml or more. The levels

rises in breast feeding mothers. With each suckling episode the level of prolactin

raises up to lOOng/ml. Therefore the frequency of breast feeding has an important

role in maintaining the prolactin level.

Serum FSH and LH

These levels during first 10-12 days after delivery are very low, irrespective of

the status of lactation. After 12 days their levels increase, by the 3rd

week their

concentration is same as in follicular phase. Low level of FSH and LH in early

puerperium is due to a reduced GnRH during pregnancy and the early post partum

period.

There is also reduction in the secretion of GnRH, Growth Hormone, Insulin,

Thyroid Hormones and even the secretion of ACTH. There is relative normal or high

level of these hormones during pregnancy, which reduces soon after parturition.

Again all these levels are stabilized by 6-8 weeks of postpartum period.

Lactation36,38

The major physiological event of the puerperium is the establishment of

Lactation. The humoral and neural mechanisms involved in lactation are complex.

Progesterone, estrogen, cortisol, placental lactogen as well as prolactin appear to act

in concert to stimulate the milk secreting apparatus. 8,37

Mainly prolactin helps in milk production and oxytocin helps in ejection of

milk. Release of prolactin acts upon the glandular cells of the breast to stimulate milk

secretion and the second induces the release of oxytocin which acts upon the



myoepithelial cells of the breast to induce the milk ejection reflex. This milk ejection

reflex is mediated by the release of oxytocin from the posterior pituitary gland. It is

readily inhibited by the emotional stress, maternal anxiety etc which frequently leads

to a failure of lactation.

Both estrogen and progesterone are necessary for mammary development in

pregnancy but prolactin, growth hormone and adrenal steroids may also be involved.

During pregnancy only minimal amounts of milk is formed in the breast despite high

levels of the Placental lactogenic hormones and even prolactin. This is because the

actions of these lactogenic hormones are inhibited by the secretion of high levels of

oestrogen and progesterone from the placenta and it is not until after delivery that

copious milk production is inhibited.

The composition of breast milk varies according to the age of the baby and

from the beginning to end of the feed. Colostrum is the breast secretion of the mother

in the first few days after delivery. It is a deep yellow coloured thick serous secretion

having high specific gravity and alkaline reaction, contains high protein, vitamin A,

sodium and chloride. More of antibodies (IgA, IgG, IgM), white blood cells and other

anti infective proteins in colostrum provides immunological defence to the new born.

This colostrum also has a mild purgative effect, which helps to clear the baby's gut of

meconium. This clears bilirubin from the gut and thus helps to prevent jaundice.8

The milk secreted later is having more fat and lactose but less protein. The

long chain poly unsaturated fatty acids present are important for neuro developmental

consequences for the baby, ie, it helps in myelination of central nervous

system.Facilitates absorption of calcium. The ammo acids like taurine and cystein

which are important neurotransmitters. Breast feeding protects the infant against

infection ie, prevents gastrointestinal illness (diarrhea), respiratory tract infections etc.



The protective factors like IgA, Macrophages, lymphocytes, Complements and

interferon etc. present are very much important in this aspect.8

Table No - 2 Composition of colostrum and Breast milk8

Protein

Fat

Carbohydrates

Water

Colostrum

8.6%

2.3%

3.2%

86%

Breast milk

1.2%

3.2%

7.5%

87%

. The proteins present are lactalbumin, lacto globulins, lactoferrin and casein.

. Among carbohydrates mainly lactose along with glucose and

galactose.

. Mainly triglycerides (olein, palmitin, stearin) in fats.

. Vitamins like B.C.D with abundance of Vitamin A and exception of Vitamin K.

There is no doubt that breast milk is the ideal nutrition for the New born baby.

Highly nourishing, easily digestible and immunizing contents in mothers milk

necessitates the exclusive breast feeding during first 6 months of neonatal life. A

healthy mother will produce about 500 - 800m] of breast milk a day to feed her infant

with about 500kcal/day. In well established lactation, it is possible to sustain a baby

on breast milk alone for 4-6 months. This requires about 600 k cal / day for the

mother which must be made up from the mothers diet or from her body store. For this

purpose a store of about 5 kg of fat during pregnancy is essential to make up any

nutritional deficit during lactation.



Breast feeding accelerates the process of uterine involution in mother.40

reducing the chances of post partum hemorrhage, Improves post partum weight loss39

,

In exclusively breast fed mothers it provides 98% protection against pregnancy for

first 6 months. It also lowers the risk of breast cancer and ovarian cancer. Lactation or

breast feeding or nursing the child - What ever the terminology it strengthens the

psychological bonding between mother and the baby.

Care of Puerperium8,36,37,38

The care of a pregnant woman does not end with the delivery of the child and

the conclusion of the 3rd

stage of labour. Even pregnancy should be considered as a

natural, physiological event, Management and care of the delivered lady is a must.

So the main objectives of puerperial management are –

To monitor the physiological changes of puerperium.

To diagnose and treat any postnatal complications.

To establish infant feeding.

To give the mother emotional support.

To advise about contraception and other measures, will contribute in

continuing her health.

Immediately following delivery, lady may be given a drink or something to eat if

she is hungry. Close monitoring of general health (BP, Pulse, Temperature, vaginal

bleeding, P/A size of the uterus etc) of the lady and adequate bed rest is must.

Rooming in, ie, keeping the infant with the mother, is very important, it builds up the

parent-infant bonding.



New mother is made ease by proper care of vulva, episiotomy wound, breast

and nipple care. Proper feeding methods, care of bowel and bladder are advised. The

lady is moved out of bed with in 48hrs of post partum. By early ambulation, she feels

stronger and better, Bladder complications leading to catheterization and even

complaints of constipation are less frequent. Adequate fluid intake, liberalization of

nourishing and fiber rich diet is necessary to prevent constipation. Bladder is to be

emptied by the patient as frequently as possible.

Proper aseptic care, perineal wound dressing, observing the involution of

uterus and lochial discharge is a part and parcel of the puerperial management. For all

these necessary care and advice a minimum of 3-5 days of Hospital stay is needed.

Correction of anaemia in puerperial women is done by supplementation of iron

therapy ie, ferrous sulphate 200mg daily and also with a supplementation of calcium 1

SQOmgdaily, for 4-6 weeks.8 'After pains' in puerperium may need the help of

analgesics.40

Post Natal Exercises -8,38,39

Post natal postures and exercises must be taught for better puerperial

rehabilitation. Softness of elastic ligaments and collagenous connective tissue persists

for 4-5 months after delivery. The abdominal muscles are stretched and elongated

during pregnancy. Hence entire abdominal wall is weakened.

If the back is not properly held (incorrect postures during lifting weight) it is

vulnerable to injuries. The pelvic floor is also weakened during pregnancy due

continuous support of the gravid uterus, stretching and trauma during delivery. The

perineum is stretched and sometimes may have tears or episiotomy. Hemorrhoids may

cause severe pain; legs may be painful or swollen.



The management starts with breathing exercises and free hand movements of

the body parts. Deep breathing is helpful for relaxation and improving circulation.

Movement of the foot, ankle and leg also improve circulation. Proper Postures,

lactating methods are important in prevention of future back ache etc. Correct

postures itself will tone up the back muscles.

Pelvic floor exercises are must and to be started as early as possible. Repeated

contraction and relaxation of the pelvic floor muscles will help in regaining the tone

and elasticity. Abdominal muscle exercises are essential to regain the size of over

stretched muscles and to prevent divarication of recti. For this lady should be in dorsal

position, with knee flexed, abdominal muscles are contracted and relaxed

alternatively. Again she should lie on her face, then head and shoulders are slowly

moved up and down. The procedure is to be repeated 3-4 times a day. These Exercises

should be continued for at least 3 months.

The main advantages of these exercises are –

It minimise the risk of puerperial venous thrombosis by promoting arterial

circulation and preventing venous stasis.

It prevents back ache.

It prevents genital prolapse and stress incontinence of urine.



PUEPERAL AFTER PAINS

*Definitions of after pains by medical dictionary.

After Pains- painful cramplike contractions of the uterus occurring after

childbirth.46.1

After Pains- cramp like pains following the birth of a child due to uterine

contractions.46.2

After Pains- cramps or pains following child birth, caused by contraction of the

uterus.46.3

After Pains- a popular term for lower abdominal cramping and uterine contractions

that typically occur after vaginal delivery of the baby.46.4

After Pains- painful cramp like contraction of the uterus occurring after child

birth.46.5

AFTER PAINS

After pain is the pain resulted from the rapid and intermittent contractions of

the uterus,after the exit of placenta and membranes52

.It is felt in lower abdomen and

lower back similar to delivery pain53

.The severity is similar to that of menstrual

cramps with severe discomfort,and is sometimes worse than delivery pain52,53

.It

usually continues for 3-4 days and rarely last one week after delivery54

.Hold Croft

reported that more than 80% of women experienced after pains and this pain could

continue for one week after discharge from hospital55.



Any Factor which causes a delay in the process of uterus contractions and

interrupts appropriate restoring to the pre-pregnanacy status is effective in increasing

after pains.After pains is influenced by many factors which are as follows.

Multiparity56

, over distended uterus due to big baby, multiple gestation56

,

polyhydraminous56

, breastfeeding53

, assited delivery with tools56

, administration of

medications during and after delivery to facilitate the delivery or prevent PPH,

analgesia during delivery53

, the placenta removed by hand56

, mothers physical nad

psychological disorders53

, consumption of magnesium sulphate during pregnancy,

history of nacrotics use and chronic pain, full bladder56

, mothers delivery

position.cultural factors such as mothers race, religion and knowledge.

In primi paras, the puerperal uterus tends to remain tonically contracted unless

blood clots, fragments of placentas or other foreign bodies are retained in its cavity,

causing hypertonic contractions in an effort to expel them.

In multiparas especially the uterus often contracts giving rise to painful

sensation that are known as after pains and that occasionally are sufficiently severe to

require an analgesic, in some patients they may last for days.

After pains are particularly noticeable when the child is put to the breasts

presumably because of release of oxytocin ordinarily however they decrease in

intensity and become quite mild after the 48 Hours immediately following delivery.



AFTER PAINS

The cramps known as afterbirth pains or simple afterpains, are caused by

contraction of the uterus as it returns to its prepregnancy size after the birth of the

baby-this process is called involution43

.

Afterpains are typically mild for first time moms and don’t last long. But they

can be quiet uncomfortable after a second delivery and usually get worsen with each

successive delivery. That’s because first time moms tends to have better uterine

muscle tone, which means the uterus can contract and stay contracted rather than

relaxing and contracting intermittently43

.

Cramping will be most intense for first day or two after giving birth, but it

should taper off around third day, though it can take six weeks or longer for the uterus

to return to its normal size43

.

Breast feeding can bring on after pains or make them more intense because the

baby’s sucking triggers the release of the hormone oxytocin,which in turn causes

contractions.This is actually a good thing ,the cramps brought on by breast feeding

helps the uterus shrink to normal size more quickly, reducing the risk of postpartum

anaemia from blood loss43

.

Post partum cramps are uncomfortable pains which signals that the body is

getting back to its non pregnant state.They remain for few days after child birth and

vary in their frequency44

.



# How long do Afterpains last (in weeks)

It takes about six to eight weeks for the uterus to return to its pre-pregnant size and

severe pain last only for one or two days post delivery.

# Causes of pains and cramps

While pressure and strain on the body post delivery are the main causes of pain,there

are other reasons as well.

1) During pregnancy, the uterus expands up to 25 times its normal and it as large as

the basket ball.It then shrinks to a size of a tiny pear.This shrink causes after birth

pains and cramps or involution.

2) Breast feeding is another cause for pains ans cramps after pregnancy.The babys

sucking stimulates the production of oxytocin which leads to contraction and thus

pain.

3) If there was C-Section then there will abdominal pain along with pulling sensation

that last for a long period.

Few tips to minimize the discomfort.

. Try to pee often,even if ther is no urge to go.A full bladder displaces the uterus so it

cant contract completely.

. Lie face down with a pillow under your abdomen.

. Lie face down with a warm heating pad under your belly.

. Gently massage the lower belly.



Home remedies for relieving after birth pains.

1) Hot Water Compress;

Hot water treatment is the best way to cure unpleasant abdomen tenderness

and suffering as it loosens contracted uterus and improves blood circulation

thereby relieving lower abdomen and uterus pain.

2) Rice Water

Cook rice with extra water and drink the strained water twice a day this water

soothens the stomach region,improves digestion and prevents constipation.

3) Ginger Tea

Ginger is anti inflammatory and an excellent astringent.and antiseptic which

prevents pains and cramping after birthby relieving abdominal and hip pains.

Make ginger tea by adding grated ginger to a cup of boiling water,you can also

add 10 parseley leaves and them together for sometime,add honey to taste and

have it twice a day.

4) Fennel Tea

Fennel seeds also have anti inflammatory and analgesic properties that work

on relieving post pregnancy pain.



5) Warm Water Bath

Bathing in warm water will alleviate hip and uterus pains.You can soak in a

bath tub for about 30 mins but ensure that temperature is not so hot.

6) Oil Massage

Gently massage the abdomen with oil mix.To make oil mix take 5 drops of

lavender oil,10 drops of cypress oil,15 drops of peppermint oil and one ounce

carrier oil(Jojoba,Olive,Sweet almond or coconut oil).To massage place hand

on navel and move in circular motion,as it will stimulate contractions and

make uterus firm.

AFTER PAINS, PAINS AFTER LABOUR/DELIVERY45

After labour and birth you may have pains or soreness in your whole body.It

happens because of laboring in different position and pushing. Body undergoes

tremendous changes throughout the nine months of pregnancy and in just 6 weeks

afterwards organs return to their normal or previous state during this process few

transformation may cause some or more discomfort to the body.

After pains are those pains when body works hard to get recovered by the

presence of uterine contractions after childbirth these contractions serve the important

function of clamping off open blood vessels at the placental site, minimizing the loss

of blood after birth.



If the uterus does not contract appropriate medications and massage must be

given as mentioned in the puerperium care.The first time moms do not usually find

the after pains or postpartum uterine contraction as painful as in females who have

given birth second time.

If the lady has given birth before, the afterpains may be very painful. An

ocassionally first time moms find the afterpains much painful. One should be aware of

that persistent severe cramps or uterine tenderness could be the sign of infection. To

get ameliorated from pains try spending time lying on the abdomen, if the pains are

especially uncomfortable one can apply heating pads to the abdomen along with

medications.

Calicum consumption as supplements 500mg twice a day,during 3rd trimester of

pregnancy and postpartum period can prevent afterpains57

.Also consumption of

magnesium supplementation for treatment of leg cramps, premature uterine

contractions or pregnancy hypertension reduces the incidence of after pain and

decreases postpartum analgesic consumption.



DRUG REVIEW

With the art and skill of formulation a poisonous drug could be transmuted in to a

safe and effective drug.A simple drug could be converted in to a most potent one.

Dravya which is one of the chikitsa chatushpada, usage of it in particular diseases

depends upon the yukti of vaidya, as there is no drug which cannot be used as

medicine

Bharangyadi Kalka

In classicsa reference regarding Bharangyadi kalka that is bharangi, nagara and

devadaru in makkalla sula is available

प्रजातायां चेद्वस्मतमधूोदरेष ुिलंू मक्कल्लाख्यं.......

...........भाङ्भगीनागरदवेदारुकल्कं वोष्णाम्भसा ।

- अ.सं ३/३४-३५

Here descripton of the drugs are mentioned.

BHARANGI

Botanical Name :- Clerodendrum serratum

Naturalorder:- Verbenaceas

Classical name:-Padam, Bhramani Bharangi , Bharagvi Bhargi, Phanji, Hanjika

Bharamanyashtika etc.,

Vernacular Name :- Sanskrit- Bharngi, Kharasakah

Hindi - Bharangi

Kannada – Gantabarangi

Malayam –Cerutekku



Tamil – Sirutekku

Telgu – Gantubarangi

Description :- A slightly woody shrub with bluntly quadrangular stems and branches,

leaves usually three at a node, sometimes opposites ablong or elliptic, coarsely and

sharply serrate.

Flowers:- Blue, many in long cylindrical thyrsus with a pair of acute bracts at each

branching and a flower in the fork

Fruit:- 4-lobed purple durpe, somewhat succulent with one pyrene in each lobe.

Habitate:-Throughout India, in forest upto 1,500 m elevation

Propagation :- By seeds and vegetative method

Parts used– Roots, leaves

Chemical constituents :- Serrtagenic acid, queretaroic acid, phytoserols saponins,

two iridoid glycosides etc.,

Uses :- The roots are bitter, acrid, thermogenic anti-inflammatory, digestive,

carminative stomachic, anthelmintic, depurative, expectorant, sudorific,

antispasmodic, stimulant and febrifuge, and are useful in vitiated conditions of kapha

and vata, inflammation, dyspepsia anorexia, colic, flatulence, helminthiasis cough,

asthma, bronchitis, hicough , tumours, tubercular glands, dropsy, consumption,

chronic nastitis skin disease, leucoderma, leprosy and fevers.



Ayurvedic Properties

Rasa– Tikta, Katu, Kashaya

Guna-Ruksha, Laghu

Veerya- Ushna

Vipaka– Katu

Doshaghnata– Kaphavatashamaka

Rogaghnata– Gandamala, Vrana, Visarpa, Agnimandya shotha, Nashtartava, Kasa,

Raktavikara Gulma etc.

Karma– Shothahara, Vranapachana, Deepana Pachana, Anulomana, Raktashodhaka

Pharmacological Activities

Spermicidal, CNS depressant, anti histaminic, hypotensive,antiasthmatic, antibiotic,

antifertility, stomachic, antiallergic etc.

NAGARA

Botanical Name :-Zingiber officinale

Family :-Zingiberaceae

Classical name

Vernacular NameEnglish – Ginger

Hindi –Adarak



Kannada- Haisunti, Ardraka

Malayam – Inci, Erukkilannu

Sankrit –Ardrakam

Tamil – Inci

Telgu –Allamu Ardrakamu

Description :-A slender, perennial rhizomatous herb,

Leaves:-Linear, Sessile , glabrous

Flowers:-Yellowish green in oblong,cylindrical spikes ensheathed in few scarious,

glabrous bracts

Fruits:-oblong capsules

The rhizomes are white to yellowish brown in colour, irregularly branched, some

what annualated and laterally flattened. The growing tips are covered over by a few

scales. The surface of rhizomes is smooth and if broken a fewfibrous elements of the

vascular bundles project out from the cut ends.

Habitate:- cultivate throughout India run wild in some place in western ghats

Propagation: - By rhizomes

Parts used: - Rhizomes (raw as well dry)

Chemical constituents - ∞ curcumene

β D- curcumene

∞ -bergamotene



β – bourborenene

β- camphene

d- bornealand its acetate calamine

car -3- ene

∞ - cedrol

citral

citronellol

Uses: - The raw ginger is acrid thermogenic carminative laxative and digestive, it is

useful in anorexia, vitiated conditions of vata and kapha, dyspepsia, pharyngopathy

and inflammation.

The dry ginger is acrid, thermogeic, emollient appetizer, laxative, stomachic,

stimulant rubefacient anodyne, aphrodisiac, expectorant anthelmintic and carminative.

It is useful in dropsy, otalgia, cephalagia, asthma, cough, colic, diarrhea, flatulence,

anorexia, vitiated condition of vata and kapha, dyspepsia, cardiopathy,

pharyngopathy, cholera nausea, vomiting, elephantiasis and inflammation.


Rasa– katu

Guna- Laghu, snigdha, Guru, Tikshna

Veerya- Ushna

Vipaka – Madhura

Doshaghnata – Vatakaphashamaka

Rogaghnata – Amvate, Sandhishotha, Udarashoola, Anaha, Vibandha, Vatavyadhi,

Katishool, Gulma, Adhmana , Prasavottara daurbalya etc.,

Karma – Vedanasthapana, Vatashamaka, Rochana Deepana, shoolaprashamanna,

Vatanulomana shothahara etc.,



Pharmacological Activities :- Anti inflammatory, hypolipidaemic,

antiemetic,antipyretic antioxidant, analgesic, anti bacterial, anti fungal etc,.

DEVADARU

Botanical Name–Cedrus Deodara

Classical Name:- Devadru, Darubhadra, Daru, Indradaru, Mastdaru, Drukilima,

Surbhuruha.

Vernacular Name :- Sankrit -Devadru

English- Doedar, Himalayan Cedar, True Cedar

Hindi- Debdar , Deyodar

Kannada –Devadaru

Malayam –Devataram

Tamil –Tevataram, Tevatazu

Telgu –Devadau

Description :- A large handsome evergreen conifer tree reaching up to 85 meter in

high with almost rough, black, furrowed bar and spreading branches

Shoots- Dimorphic

Leaves:- Needle like triquetors, sharp pointed, Male cones - solitary, cylindrical at

ends of the branches. Female cones- solitary at the ends of the branchlets composed

of imbricating thin woody placental scales.



Seeds :- Pale brown, wings longer than seeds

Habitate :- Himalayas in areas of elevation from 1,050 to 3600 mtrs

Propagation:- By seeds

Parts used :- leaves, heart wood, oil, bark, resin

Chemical constituents:- It is contains himachalol, allohimachalol, himadarol

centdarol, Isocentdarol, Dewarene, Dewarol, dewardiol, taxifolin, cedeodarin,

dihydromyricetin, cedrin, cedrinoside, dihydrodehyadrodiconiferyl alcohol.

Uses:- The leaves are bitter, acrid and thermogenic an are useful in inflammations and

tubercular glands.

The heart wood:- Is bitter, acrid, thermogenic emollient, anodyne, anthelmintic,

digestive, carminative, cardiotonic, galacto purifier, anti-inflammatory, diuretic,

expectorant diaphoretic, antiseptic, laxative and febrifuge and is useful in

inflammation, dyspepsia, cephalagia, haemorrhodis, insomnia, epilepsy, hiccough,

bronchitis, tubercular glands diabtes, urethrorrhea, renal and vesical calculii

elephantiases, fever, cardiac disorders, leucoderma skin disorders proctoptosis and

vitiated conditions of vata and kapha

The oil is antiseptic, diaphoretic, depurative diuretic and is useful in leprosy syphilis,

skin disease, wounds, and ulcers, fever and strangury


Rasa– Tikta

Guna- Laghu, Snigdha



Veerya- Ushna

Vipaka – Katu

Doshaghnata– Kaphavata Shamaka

Rogaghnata – Vedana, Sandhivata, Shotha, Adhamana karnashoola, Shirashoola,

Sutika roga etc.,

Karma– Shothahara, Vedanasthapana, Kushthagna, Garbhashaya

shodhana,Stanyashodhana, Deepana Pachana, Anulomna

Pharmacological Activities :- Spasmolytic, anti inflammatory antibacterial, anti

fertility, anti fungal, anti viral, antiseptic, anlegsic etc.,

Here the description along with reference of Hingu is mentioned.

स्हङ्ग ुििंु ससस्पभष्कं भकंु्त मक्कल्लिलूनतु ्॥

- यो.म.८

Here Shuddha hingu is advised along with ghrita in sutika makkalla.

HINGU

Botanical Name :- Ferula asafetida

Family:- Apiaceae, Umbelliferae

Classical name :- Hingu, Bahlika, Ramatha

Vernacular Name :- Sankrit – Hingu

English – Asafoetida

Hindi – Himg



Kannada – Hingu

Malayam – K.Yam,Karikk.yam,perunk. yam

Telgu –Ingwya

Description :- A herbaceous pernennial with fleshy, massive, carrot shaped root with

one or more forks

Stem:- 1.8 – 3 m high, solid, clothed with memberanous leaf sheaths .

Leaves:- Radical 45 cm long, shiny, coriaceous with pinnatifid segments and

channeled petiode.

Flowers :-10-20 in the main and 5-6 in the partial umbels

Fruits:-Flat, thin, reddish brown

Habitate:- wild in Punjab, Kashmir, Iran Afghanisthan .

Propgation:- By seeds and vegetitave method

Parts Used :-Resionous exudates of the root, oleo-gum-resin, leaf, stem, root

Chemical Constitutent :- The gum resin contains the coumarins 5- hydroxy-

umbelliprenin, 8-hydroxyum- belliprenin, 9- hydroxy umbellipernin,8- acetoxy 5-

hydroxyumbel- lipernin, assofoetdin , ferocolici, asacoumarin A and B,farnesiferol

A-B and C and the disulphides asadisulphide and sec-butylpropenyl disulphide.

Uses :- The oleo resin is bitter acrid, carminative antispasmodic, expectorant,

anthelmintic,diuretic, laxative, nervine tonic, digestive sedative and emmenagogue. It

is used in flatulent colic, dyspepsia asthma, hysteria, constipation , chronic



bronchitis, whooping cough, epilepsy, pyschopathy, hepatopathy, splenopathy and

viatiated conditions of kapha and vata.


Rasa – Katu

Guna- Laghu,Snigdha, Tikshna

Veerya- Katu

Vipaka – Ushna

Doshaghnata –Kaphavatashamaka, Pittavardharaka

Rogaghnata– Udarshoola, Hridyashool, Pakshaghata, Ardita, Agnimandya,

Garbhadosha, Shirashoola, Mootraghata, Bastishoola, Vibandha etc.

Karma – Vedanasthapana, Vataharaya, Shoolprashamana, Anulomana, Rochna

Pachana, Artavajnana

Pharmacological Activities :- Plant was reported to have antispasmodic

abortfacitent, anti implantation, emmenagogue antibacterial, pungent,

Anticarcinogenic, Hypotensive activities



Ghrita - It is used as anupana with hingu.

Qualities – It does pitta and vata shaman

It does not increases the kapha

It provides the bala

It is beneficial for the skin

It does shodhana of yoni marga.

Ghrita is sheeta virya and with ushna jala it spreads all the minute

channels of the body and shows its karya.

Drug

Latin name

Rasa

Guna

Veerya

Vipaka

Karma

Bharangi Clordendrum

Serratum

Tikta

Katu

Laghu

Ruksha

Ushna Katu Kaphavatahara

Nagara Zingiber

officinale

Katu Guru

Ruksha

Tikshna

Ushna Madhura Vatakaphahara

Dipaniya

Bhedaniya

shoolprashamana

Devadara Cedrus

deodara

Tikta

Katu

Kashya

Ruksha

Laghu

Ushna Katu Kaphavatahara

Dipaniya kashara

Table No.4 Drug of Shuddha Hingu

Hingu Ferula

asafetida

Katu Laghu

Snigdha

Tikshna

Ushna Katu Kaphavatahara,

Sulahara

Anulomana



Preparation of the kalka.

Dry raw drugs is powdered and filtered through thin cloth then this is

trichurated in khalwa with addition of little water to form a fine paste

The dose of kalka as mentioned in texts is 1tola or 1 karsha,i.e.12

gms.Therefore here 6 gms BD is the selected dose of Bharangyadi

kalka.

Hingu shodhana is done by frying it in ghee and then powered and

used for administered.By doing so the teekshanata of hingu is

reduced.



THE DRUGS OF BHARANGYADI KALKA



HINGU



PREPARED BHARANGYADI KALKA



HINGU POWDER

Methodology


“A COMPARATIVE CLINICAL STUDY TO EVALUATE THE EFFICACY

OF BHARANGYADI KALKA AND SHUDDHA HINGU IN THE

MANAGEMENT OF SUTIKA MAKKALLA W.R.T PUERPERAL AFTER

PAINS”

AIM AND OBJECTIVES :-

To study the sutika makkalla sula in detail

To study the efficacy of Bharangyadi Kalka in sutika makkalla.

To study the efficacy of Shuddha hingu in sutika makkalla.

To compare effect of Bharangyadi Kalka and Shuddha hingu in sutika makkalla.

HYPOTHESIS

H0 - There is neither effect of Bharangyadi Kalka nor shuddha Hingu in Sutika makkalla.

H1 - There is significant effect of Bharangyadi Kalka than shuddha Hingu in makkalla.

H2 - There is significant effect of shuddha Hingu than Bharangyadi Kalka in Sutika

Makkalla

MATERIAL AND METHODS :-

SOURCE OF DATA

a) Subjects :-

Patients were selected from OPD and IPD of Dept. of Streeroga- Prasuti Tantra, RPK

Ayurvedic Hospital Ilkal.

Methodology


b) Literary :-

Literary aspect of study is collected from classical ayurvedic and modern texts in details

and internet and journals.

c) SELECTION OF DRUG :-

* Bharangyadi kalka2 reference is from Ashtanga Sangraha Sharira Sthana.

* Shuddha Hingu10

reference is from Yogaratnakar Streeroga Adhikar Chikitsa.

d) Collection of drug :-

The trial drugs required for the preparation of medicine were collected from local

areas and market.

e) PREPARATION OF MEDICINE :-

Raw Materials were collected from market and kalka was prepared freshly in front

of the patent at the time of the administration.

द्रव्यमार्द ंशिलाशिष्ट ंिषु्कै वा सजलं भवते ्॥ - िा.सं.५/१

Talble No, 5 A. Bharangyadi kalka :

Drugs Latin name Quantity

Bharangi moola

Choorna

Clerodendrum Indicum 2 gms

Nagara Zingiber Officinale 2 gms

Devadaru twak Cedrus deodara 2 gms

Methodology


Procedure : 17

Above drugs are taken and kalka will be prepared as per classical

reference.

B. Shuddha Hingu :

The shodhana of hingu is done by frying in ghrita and then used for administration18

according to the dose decided.

METHODS OF COLLECTION OF DATA :- OPD and IPD Patients from PTSR

Department of RPK Ayurvedic Hospital, Ilkal were taken for study.

a) Study Design :-

A Randamized comparative clinical study – where 30 patients screened of sutika

makkalla were selected.

b) Sample Size :-

30 patients will be included

Group –A :- 15 diagnosed patients of Sutika Makkalla were treated with

Bharangyadi Kalka 6 gms twice orally before food for five days.

Group –B :- 15 diagnosed patients with sutika makkalla were treated with Shuddha

Hingu 125 mg twice orally before food for five days.

c) Diagnostic Criteria :-

- Udara shoola

- Nabhi shoola

- Basti shoola

- Suchivat vedana in pakwashaya

- Mootrasanga

- Adhmana

Methodology


SELECTION CRITERIA :-

d) Inclusion Criteria :-

* Women who have undergone vaginal delivery.

* Sutika having classical signs and symptoms of makkalla sula.

* Preterm and postdated vaginal delivery

* Sutika complaining of makkalla shoola from the time of delivery upto 5 days.

e) Exclusion Criteria :-

* Sutika having undergone L.S.C.S Assisted delivery (vacuum, forceps delivery)

*Sutika with severe anaemia (less than 8 gm %)

*Sutika with HTN, DM, APH, PPH, prolonged labour.

*Sutika undergone any lower abdominal surgeries in past.

*Sutika having any ovarian or uterine pathology.

* Retained or manual removal of placenta

f) ASSESSMENT CRITERIA

Statistical analysis done after accessing the pre and post medication data of subjective and

objective parameters.

SUBJECTIVE PARAMETERS :-

► Pain abdomen

►Stanya pravartana

Methodology


OBJECTIVE PARAMETERS

► P/A uterine involution

► Lochia

g) INTERVENTION:-

Group – A

Drug - Bharangyadi kalka

Dose - 6 gram twice daily before food (pragbhakta)

Duration – 5 days

Route – Oral

Anupana – Ushna Jala

Follow up period – On 6th

day of treatment

On 15th

day of treatment

On 30th

day of treatment

Total duration - 30 days

Group – B

Drug - Shuddha Hingu

Dose - 125 mg. twice daily before food (pragbhakta)

Duration – 5 days

Route – Oral

Anupan – Ghrita

Follow up period – On 6th

day of treatment

On 15th

day of treatment

On 30th

day of treatment

Total duration – 30 days

Methodology


STATISCTICAL ANALYSIS : Chi –Square/Fisher Exact test has been used to find the

significnance of study parameters on categorical scale between two or more grpous, Non-

parametric setting for Qualitative date analysis. Mann Whitney U test as Non-parametric U

test has been used to find the significance of score of study variables in two groups.

GRADINGS OF SUBJECTIVE PARAMATERS

Udara Shoola

Grade – 0 – No pain

1- Mild pain (Pain while walking )

2- Moderate pain (Pain in sitting standing)

3- Severe Pain (Pain on lying on bed rest)s

Stanya Pravartana

Grade- 0 –Absent

1- Inadequate

2- Adequate

3- Excessive

Methodology


GRADINGS OF OBJECTIVE PARAMETERS:-

Involution of uterus :-

Grade-0- No involution (Fundus at the level of umbilicus)

1- 0- 1.25 cm of involution (below umbilicus)

2- 1.25-5 cm of involution (below umbilicus)

3- 5-10 cm of involution (below umbilicus)

4-10-13.5 cm of involution (below umbilicus)

5- Completely involuted (Not Palpable)

LOCHIA

Grade – 0 absent

1- Mild (1-2 pads / day)

2- Normal (2-3pads / day)

3- Moderate (3-4 pads / day)

4- excessive (more than 4 pads / day)

Observations and Results


OBSERVATIONS

Table 6: Age distribution of patients studied

Age in years Group A Group B Total

18-20 8(53.3%) 0(0%) 8(26.7%)

21-25 5(33.3%) 8(53.3%) 13(43.3%)

26-30 2(13.3%) 7(46.7%) 9(30%)

Total 15(100%) 15(100%) 30(100%)

Mean ± SD 21.33±2.72 25.20±2.78 23.27±3.34

P=0.001**, Significant, Student t test

Graph No. 1 Age distribution in two groups patients studied

Among the 30 patients included in this study 26.7% of the patients were in the age

group of 18-20 years, 43.3% of the patients were in the age group of 21-25 years,

30% of the patients were in the age group of 26-30 years



Table 7: Education distribution in two groups of patients studied

Education Group A Group B Total

Illiterate 5(33.3%) 2(13.3%) 7(23.3%)

SSLC 5(33.3%) 6(40%) 11(36.7%)

PUC 4(26.7%) 4(26.7%) 8(26.7%)

Graduate 1(6.7%) 3(20%) 4(13.3%)

Total 15(100%) 15(100%) 30(100%)

P=0.519, Not Significant, Fisher Exact Test

Graph No.2 Education distribution in two groups patients studied

Among the 30 patients included in this study 23.3 % of the patients were illiterate,

36.7% of the patients were studied SSLC, 26.7% of the patients were studed PUC,

13.3% of the patients of were graduate.



Table 8: Occupation distribution in two groups of patients studied

Occupation Group A Group B Total

Housewife 15(100%) 14(93.3%) 29(96.7%)

Office Job 0(0%) 1(6.7%) 1(3.3%)

Total 15(100%) 15(100%) 30(100%)


Graph No.3 Occupation distribution in two groups patients studied

Among the 30 patients included in this study 96.7% of the patients were housewifes,

3.3% of the patients were job goers



Table 9: Social Status distribution in two groups of patients studied

Social Status Group A Group B Total

Lower 7(46.7%) 4(26.7%) 11(36.7%)

Middle 7(46.7%) 7(46.7%) 14(46.7%)

High Class 1(6.7%) 4(26.7%) 5(16.7%)

Total 15(100%) 15(100%) 30(100%)


Graph No.4 Social status distribution in two groups patients studied

Among the 30 patients included in this study 36.7% of the patients were of lower

class, 46.7% of the patients were of middle class, 16.7% of the patients were of high

class.

Table 10: Religion distribution in two groups of patients studied



Religion Group A Group B Total

Hindu 11(73.3%) 14(93.3%) 25(83.3%)

Muslim 4(26.7%) 1(6.7%) 5(16.7%)

Total 15(100%) 15(100%) 30(100%)


Graph No.5 Religion distribution in two groups patients studied

Among the 30 patients included in this study 83.3% of the patients were Hindu,

16.7% of the patients were Muslims

Table 11: Obstetric History distribution in two groups of patients studied



Obstetric

History Group A Group B Total

Primi 9(60%) 6(40%) 15(50%)

Multi 6(40%) 9(60%) 15(50%)

Total 15(100%) 15(100%) 30(100%)

P=0.273, Not Significant, Chi-Square Test

Graph No.6 Obstetric History distribution in two groups patients studied

Among the 30 patients included in this study 50% of the patients were primipara,

50% of the patients were Multipara.

Table 12: Diet distribution in two groups of patients studied



Diet Group A Group B Total

Mixed 10(66.7%) 8(53.3%) 18(60%)

Veg 5(33.3%) 7(46.7%) 12(40%)

Total 15(100%) 15(100%) 30(100%)

P=0.456, Not Significant, Chi-Square Test

Graph No.7 Diet distribution in two groups patients studied

Among the 30 patients included in this study 60% of the patients were taking mixed

diet, 40% of the patients were vegetarians.

Table 13: Prakruthi distribution in two groups of patients studied



Prakruthi Group A Group B Total

Vata pitta 9(60%) 3(20%) 12(40%)

Vatta 1(6.7%) 8(53.3%) 9(30%)

Vata kapha 4(26.7%) 1(6.7%) 5(16.7%)

Pitta 1(6.7%) 3(20%) 4(13.3%)

Total 15(100%) 15(100%) 30(100%)

P=0.006**, Significant, Fisher Exact Test

Graph No.8 Prakruthi distribution in two groups patients studied

Among the 30 patients included in this study 40% of patients were VP prakruti, 30%

of the patients were V prakruti, 16.7% of the patients were of VK prakruti, 13.3% of

the patients were of the P prakruti.

RESULTS

Table No.14 : UDARA SHOOLA-Assessment of study outcome in different study

points



Udara shoola D1 D2 D3 D4 D5 D6 D15 D30 %

difference

Group A

(n=15)

0 0(0%) 0(0%) 0(0%) 1(6.7%) 1(6.7%) 1(6.7%) 4(26.7%) 6(40%) 40.0%

1 4(26.7%) 4(26.7%) 7(46.7%) 9(60%) 10(66.7%) 10(66.7%) 9(60%) 9(60%) 33.3%

2 7(46.7%) 7(46.7%) 6(40%) 4(26.7%) 4(26.7%) 4(26.7%) 2(13.3%) 0(0%) -46.7%

3 4(26.7%) 4(26.7%) 2(13.3%) 1(6.7%) 0(0%) 0(0%) 0(0%) 0(0%) -26.7%

Group B (n=15)

0 0(0%) 0(0%) 0(0%) 2(13.3%) 4(26.7%) 5(33.3%) 10(66.7%) 11(73.3%) 73.3%

1 5(33.3%) 6(40%) 7(46.7%) 10(66.7%) 9(60%) 7(46.7%) 4(26.7%) 4(26.7%) -6.6%

2 7(46.7%) 6(40%) 7(46.7%) 3(20%) 2(13.3%) 3(20%) 1(6.7%) 0(0%) -46.7%

3 3(20%) 3(20%) 1(6.7%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) -20.0%

P value 0.006** 0.805 1.000 1.000 0.339 0.280 0.101 0.139 -

Chi-Square/Fisher Exact Test

Group A - On stastically analyzing the effect of treatment on Udara shoola it was

noted that there was statistically significant change. The mean score of udara shola of

which was 40% in No pain grade, 33.3% were in Mild pain grade,-46.7% were in

Moderate pain grade,-26.7% were in severe pain grade.

Group B - On stastically analyzing the effect of treatment on Udara shoola it was

noted that there was statistically significant change. The mean score of which was

73.3% in No pain grade,-6.6% were in Mild pain grade,-46.7% were in Moderate pain

grade,-20.0% were in severe pain grade.

Graph No.09 : UDARA SHOOLA-Assessment of study outcome in different

study points



Table 15: UDARA SHOOLA- Comparative assessment at different time points

in two groups studied



Udara shoola Group A Group B Total P value

D1 2.00±0.76 1.87±0.74 1.93±0.74 0.623

D2 2.00±0.76 1.80±0.77 1.90±0.76 0.463

D3 1.67±0.72 1.60±0.63 1.63±0.67 0.854

D4 1.33±0.72 1.07±0.59 1.20±0.66 0.321

D5 1.20±0.56 0.87±0.64 1.03±0.61 0.140

D6 1.20±0.56 0.87±0.74 1.03±0.67 0.178

D15 0.87±0.64 0.40±0.63 0.63±0.67 0.041*

D30 0.60±0.51 0.27±0.46 0.43±0.50 0.070+

Mann whitney U test- a non-parametric test

Graph No. 10 UDARA SHOOLA- Comparative assessment at different time

points in two groups studied

The mean difference of udara shoola in Group A was reduced from 2.00 ± 0.76 to

0.60 ± 0.51 on D30. And in Group B it was reduced from1.87 ± 0.74 to 0.27 ± 0.46 on

D30.

The difference in the mean values of the two groups shows that it is statistically

significant (P=0.070+).

Table 16: STANYA PRAVARTANA-Assessment of study outcome in different

study points



Stanya

pravart

ana

D1 D2 D3 D4 D5 D6 D15 D30

%

differe

nce

Group A

(n=15)

0 5(33.3

%)

4(26.

7%)

1(6.7

%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%)

-

33.3%

1 9(60%

)

9(60

%)

5(33.

3%)

3(20%

)

2(13.3

%)

1(6.7

%)

1(6.7

%) 0(0%)

-

60.0%

2 1(6.7

%)

2(13.

3%)

9(60

%)

12(80

%)

13(86.

7%)

14(93.

3%)

14(93.

3%)

15(10

0%) 93.3%

3 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0.0%

Group B

(n=15)

0 5(33.3

%)

5(33.

3%)

1(6.7

%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%)

-

33.3%

1 10(66.

7%)

5(33.

3%)

6(40

%)

4(26.7

%)

1(6.7

%) 0(0%) 0(0%) 0(0%)

-

66.7%

2 0(0%) 3(20

%)

6(40

%)

10(66.

7%)

12(80

%)

15(100

%)

15(100

%)

15(10

0%)

100.0

%

3 0(0%) 2(13.

3%)

2(13.

3%)

1(6.7

%)

2(13.3

%) 0(0%) 0(0%) 0(0%) 0.0%

P value 1.000 0.406 0.608 0.682 0.598 1.000 1.000 1.000 -


Group A - On statistically analyzing the effect on treatment on Stanya

pravartana it was noted that there was no significant change.The mean score of stanya

pravartana of which was-33.3% in absent grade, -60% in inadequate grade, 93.3% in

adequate grade, 0.0% in excessive grade.

Group B -On statistically analyzing the effect of treatment on stanya

pravartana it was noted that there was no significant change.The mean score of which

was -33.3% in absent grade, -66.7% in inadequate grade, 100% in adequate, 0.0% in

excessive,grade.



Graph No. 11 STANYA PRAVARTANA - Comparative assessment at different

time points in two groups studied



Table 17: STANYA PRAVARTANA-Comparative assessment at different time

points in two groups studied

Stanya

pravartana Group A Group B Total P value

D1 0.73±0.59 0.67±0.49 0.70±0.53 0.806

D2 0.87±0.64 1.13±1.06 1.00±0.87 0.593

D3 1.53±0.64 1.60±0.83 1.57±0.73 0.927

D4 1.80±0.41 1.80±0.56 1.80±0.48 0.936

D5 1.87±0.35 2.07±0.46 1.97±0.41 0.190

D6 1.93±0.26 2.00±0.00 1.97±0.18 0.317

D15 1.93±0.26 2.00±0.00 1.97±0.18 0.317

D30 2.00±0.00 2.00±0.00 2.00±0.00 1.000


Graph No.12 STANYA PRAVARTANA-Comparative assessment at different


The mean difference of stanya pravartana in group A was increased from 0.73±0.59 to

2.00±0.00 on D30. And in group B it was increased from 0.67±0.49 to 2.00±0.00 on

D30. There is not a statistically significant difference between the input groups

(P=1.000).



Table 18: INVOLUTION OF UTERUS-Assessment of study outcome in different

study points

Involution of

uterus D1 D2 D3 D4 D5 D6 D15 D30

%

difference

Group I (n=15)

0 14(93.3%) 9(60%) 1(6.7%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) -93.3%

1 1(6.7%) 2(13.3%) 2(13.3%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) -6.7%

2 0(0%) 4(26.7%) 12(80%) 15(100%) 13(86.7%) 0(0%) 0(0%) 0(0%) 0.0%

3 0(0%) 0(0%) 0(0%) 0(0%) 2(13.3%) 15(100%) 5(33.3%) 0(0%) 0.0%

4 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 10(66.7%) 0(0%) 0.0%

5 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 15(100%) 100.0%

Group II (n=15)

0 15(100%) 9(60%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) -100.0%

1 0(0%) 2(13.3%) 1(6.7%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0.0%

2 0(0%) 4(26.7%) 14(93.3%) 15(100%) 10(66.7%) 0(0%) 0(0%) 0(0%) 0.0%

3 0(0%) 0(0%) 0(0%) 0(0%) 5(33.3%) 15(100%) 8(53.3%) 0(0%) 0.0%

4 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 7(46.7%) 0(0%) 0.0%

5 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 15(100%) 100.0%

P value 1.000 1.000 0.598 1.000 0.390 1.000 0.462 1.000 -


Group A-On statistically analyzing the effect of treatment on involution of uterus it

was noted that there was no statistically significant change.The mean score of

involution of uterus which was -99.3% in No involution grade, -6.7% in 0-1.25 cms

involution grade, 0.0% in 1.25-5 cms involution grade,0.0% in 5-10 cms involution

grade,0.0% in 10-13.5 cms involution grade, 100% in completelety involuted grade.

Group B- On statistically analyzing the effect of treatment on involution of uterus it

was noted that there was no statistically significant change. The mean score of

involution of uterus which was -100% in No involution grade, 0.0% in 0-1.25 cms

involution grade, 0.0% in1.25-5 cms involution grade, 0.0% in 5-10 cms involution

grade, 0.0% in 10-13.5 cms involution grade, 100% in completely involuted grade.



Graph No.13 : INVOLUTION OF UTERUS - Comparative assessment at

different time points in two groups studied



Table 19: INVOLUTION OF UTERUS-Comparative assessment at different


Involution of

uterus Group A Group B Total P value

D1 0.07±0.26 0.00±0.00 0.03±0.18 0.317

D2 0.67±0.90 0.67±0.90 0.67±0.88 1.000

D3 1.73±0.59 1.93±0.26 1.83±0.46 0.276

D4 2.00±0.00 2.00±0.00 2.00±0.00 1.000

D5 2.13±0.35 2.33±0.49 2.23±0.43 0.203

D6 3.00±0.00 3.00±0.00 3.00±0.00 1.000

D15 3.67±0.49 3.47±0.52 3.57±0.50 0.277

D30 5.00±000 5.00±000 5.00±000 1.000


Graph No. 14 INVOLUTION OF UTERUS-Comparative assessment at different


The difference in the mean values in group A was increased from 0.07 ± 0.26 to 5.00

± 000 on D30. And in group B it was increased from 0.67 ± 0.90 to 5.00 ± 000 on

D30.

There is not a statistically significant difference between the input groups (P=1.000).



Table 20: LOCHIA-Assessment of study outcome in different study points

LOCHIA D1 D2 D3 D4 D5 D6 D15 D30 %

difference

Group A

(n=15)

0 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 10(66.7%) 66.7%

1 0(0%) 0(0%) 1(6.7%) 0(0%) 1(6.7%) 0(0%) 0(0%) 0(0%) 0.0%

2 0(0%) 0(0%) 1(6.7%) 3(20%) 6(40%) 11(73.3%) 13(86.7%) 5(33.3%) 33.3%

3 9(60%) 9(60%) 12(80%) 10(66.7%) 6(40%) 4(26.7%) 2(13.3%) 0(0%) -60.0%

4 6(40%) 6(40%) 1(6.7%) 2(13.3%) 2(13.3%) 0(0%) 0(0%) 0(0%) -40.0%

Group B (n=15)

1 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 7(46.7%) 46.7%

2 0(0%) 0(0%) 1(6.7%) 0(0%) 0(0%) 0(0%) 0(0%) 0(0%) 0.0%

3 0(0%) 0(0%) 1(6.7%) 5(33.3%) 5(33.3%) 8(53.3%) 10(66.7%) 6(40%) 40.0%

4 10(66.7%) 10(66.7%) 9(60%) 9(60%) 8(53.3%) 5(33.3%) 4(26.7%) 1(6.7%) -60.0%

5 5(33.3%) 5(33.3%) 4(26.7%) 1(6.7%) 2(13.3%) 2(13.3%) 1(6.7%) 1(6.7%) -26.6%

P value 1.000 1.000 0.636 0.750 0.877 0.386 0.390 0.566 -


Group A- On statistically analyzing the effect of treatment on lochial bleeding it was

noted that there was no statistically significant change .The mean score of lochia

which was 66.7% in Absent grade, 0.0% in Mild bleeding grade, 33.3% in Normal

bleeding grade, -60.0% in Moderate bleeding grade, -40.0% in Excessive bleeding

grade.

Group B- On statistically analyzing the effect of treatment on lochial bleeding it was

noted that there was no statistically significant change. The mean score of lochia



grade.



Graph No.15 : LOCHIA - Comparative assessment at different time points in two

groups studied



Table 21: LOCHIA-Comparative assessment at different time points in two groups

studied

LOCHIA Group A Group B Total P value

D1 3.40±0.51 3.33±0.49 3.37±0.49 0.710

D2 3.40±0.51 3.33±0.49 3.37±0.49 0.710

D3 2.87±0.64 3.07±0.80 2.97±0.72 0.317

D4 2.93±0.59 2.73±0.59 2.83±0.59 0.355

D5 2.60±0.83 2.80±0.68 2.70±0.75 0.485

D6 2.27±0.46 2.60±0.74 2.43±0.63 0.195

D15 2.13±0.35 2.40±0.63 2.27±0.52 0.185

D30 0.67±0.98 1.27±1.33 0.97±1.19 0.194


Graph No.16 : LOCHIA - Comparative assessment at different time points in

two groups studied

The mean difference of Lochia in Group A was decreased from 3.40±0.51 to 0.67±0.98

on D30. And in Group B it was decreased from 3.33±0.49 to 1.27±1.33.

There is not a statistically significant difference between the input groups (P=0.194)



Discussion


DISCUSSION

DISCUSSION ON CONCEPTUAL STUDY

Mortality and morbidity of the mother the most challenging problem of our

country.Yet postpartum and postnatal period receives less attention from health care

providers than pregnancy and childbirth.In day to day life we come across the females

patient complaining of various ailments such as pain abdomen, back ache, anaemia,

joints pains and prone to infection if not taken care in the puerperial period.

Frequent postpartum morbidity and its association with perinatal outcome

suggest the need for postpartum care in developing countries for both the mother and

the child.

Post natal care is the attention given to the general mental and physical

welfare of the mother and the infant. Care should be directed towards prevention and

early detection and treatment of the sutika roga and its complications.Among the most

common and distressing complications the puerperial period are “After Pain” in multi

as well in primi paras and painful breast engorgement usually in primipara.

Sutika Makkalla one of the sutika roga is well documented in our classics

since the ancient time by our acharyas.The main causative factor of sutika makkalla is

the viatiation of the vata dosha.The Prakupita vayu localizes the unexcreated blood

and retains this blood in the uterus inspite the use of ushna teekshna dravyas,this

retained blood produces various complication and leads to Makkalla and if left

untreated can cause abcess.

Discussion


The vata dosha is the main reason for the diseases occurring in the sutika

avastha,hence all possible measures to balance the vata dosha is been done in the

study.

The paricharya mentioned in sutika is atmost important for preventing various

diseases in this period and maintain the health of the sutika so as she can take care of

herself and the baby.

Ayurveda describes the condition of sutika avastha and its various

vyadhis.The most happiest stage in the womens life.Here various paricharya

explained to sutika i.e prasavottara kala like dinacharya rutucharya has been explained

for the betterment of the health.

During the various stages of womens life as in garbha avastha, prasava

avastha,etc the chala doshas,kledha,rakta nisruthi,dhatu kshinata and shareera

shunyata after the prasava makes the sutika abala more prone to disorders caused due

to the viatiation of vata. Also due to strenuous work of the body during the various

stages of labour makes the stree abala with reduced agni because of shunyata of the

body therefore the sutika should be given the energetic and potent medications.

As the body of the sutika has undergone wear and tear she should be

administered ghrita pana as it is pittaanila hara,nourishes all the dhatus, its ojas

kara,medhya, swara varna prasadana,daha shamaka, does bala vriddhi and is vayah

sthapana.Thus sneha pana is advised in the paricharya,this sneha is good provider of

cell wall removes the wear and tear and tissue builder.It is considered as yoga vahi

which provides many essential fatty acids such as omega 6 which provides anti

inflammatory properties. Ghrta which includes 17 amino acid is essential for good

Discussion


health. It contains 3% linoleic acid, an antioxidant.It also contains Vitamin A, D, C

K.41

As the puerperial women is prone to infection such as urinary tract infection

she was advised to take plenty of liquids in form of water peya vilepi etc and

evacuation of bladder time to time.

Sutika was also advised to follow the diet and regimes according to their

culture which has been running in tradition since the olden times. Apart from the

internal medication external treatment described in classics as abhyanga, parisheka,

avagha etc all help in the mitigation of the vata dosha. All the massage therapies can

be sthanika or sarvadiahika has lot of advantages such as –It is jara hara, pushti kara,

shrama hara, vata hara, klesha sahatwa, abhighata sahatwa, dhadyakrith67

,i.e it will

definitely strengthen the sutika to tolerate the after effects of labour.it gives good

sleep and also ayush kara.

The swedana given to the stree should be according to her bala, as abala stree

should not be teeskshana sweda infact mrudu sweda in form of pariskeha and avagha

are benefical. This su ushna medicated jala dhara or immersing the body into this jala

droni is kapha vata hara does maintaining of pitta, effective in reducing the vedana

vega, does agni deepti, twak prasannata, removes muscle cramps stiffness in the

joints, heavinees of the body.This type of sweda is effective in arsha, ashmari, and

shula. This procedures act as vedana sthapana in the sutika .

The benefits of abhyanga, parisheka etc reduces and stabilizes the increased

heart rate and blood pressure, improves circulation and endo phins , cause

vasodilatation and relaxes the muscles.The Endophins are the body’s natural pain

killers. Massage improves the circulation and nervous stimulation and also exert

Discussion


smoothening effect on the body. The sudation is also a good reliever of muscular pain,

and various pain experienced by the women in puerperial period. The blood vessels

dilate as a result of heat due to sudation and increases circulation resulting in more

oxygen supply to all parts of body. This will thus help in relieving the pain local as

well as generalized pains.

As mentioned in classics the different types of sweda ,advise given to sutika to

sit on the chair of ushna charmavan filled with oil is for the purpose of yoni

prasadana. Laxiety of perineum as a result of excessive stretching during the process

of labour this ushna oil helps in regaining the pelvic floor strength. Also Nubja

shayana, udara vesthana, abhyanga not only does vayu shaman but prevents vayu

vikruthi occurring due to hollow space formed in the uterus and abdomen due the

delivery of the fetus.The sutika snana followed by dhupana, and vishranti are vata

hara and shramahara.

After the process of delivery the the sutika is prone to infections especially the

genital tract due to dilated tract. So it was advised for yoni dhupana which acts as

antibacterial, maintaines the hygiene of perineum, keeps episotomy healthy along

with hastening in the healing process. The drugs used for the purpose having

jantugna, kandugna, sthohara, vedana sthapana, vrana shodhana and ropana

properties. Due to all the above measures advised to the sutika helped her regain her

lost strength, healing of wound, reduction of perineal tenderness.

Researches show that sudation helps in relieving pain and speed up the healing

process.Fumigation with Agaru acts as pain reliever of the wounds and ulcers,

Guggulu acts as a anti infective.The essential oils of the roots of Kustha and the

Discussion


glycosides are pharmacologically active bodies which has carminative , antiseptic and

disinfectant thus having destructive effect against the streptococcus and

staphylococcus bacteria.

No shodhana procedures are advised in sutika avastha since there is no

bahudosha avastha in lady after giving birth.Only by following the samanya sutika

paricharya will get back her the qualities of swastha28

.

Puerperium is the period following birth of the child during which all the body

tissues revert back approximately to the pre-pregnant state. The International

Conference on Population and Development 1994 defines reproductive health as the

state of complete physical , mental, and social well being and not merely the absence

of disease or infirmity in all matters relating to reproductive system and to its

functions and process.

It is well known that certain psycho-somatic changes takes place during the

sutika kala such as weigth loss, loss of body fluids, lacerated genital tract, pain lower

abdomen, back pain, constipation, mental stress etc. Most of the changes leads to

apatarpana of the stree 65

and this causes vata vriddhi which is responsible for

different types of health problems such as puerperial sepsis, anaemia, prolapse of

uterus. This disorders are difficuilt to treat and some become incurable. The risk

factors could be partially be reduced by facilitating early recovery process. So the

management of sutika and its vyadhis is essential to ,promote recovery of maternal

health so that the mother may become able to resume her normal activities as early as

possible.

Discussion


Ayurveda emphasis much importance of the care of women especially in the

prenatal and postnatal period, Sutika is the state of women immediately after delivery

extends till the time she continues breast feeding. Sutika refers to women after

expulsion of placenta .The sound puthramsutte brings back the jeeva i.e the life in the

parturient women, but this is possible if her health is taken care during the postnatal

period. The period after prasava is called as sutika avastha .Puerperium begin as soon

as the placenta is expelled and last for approximately 6 week when the uterus

becomes regressed to non pregnant state. The women becomes emaciated and have

shunya shareera because of garbha vriddhi, shithila sarva shareera dhatu, pravahana

vedhana, kledha rakta nisruti,agni mandya will lead to dhatushaya hence extra care to

be given to prevent the 74 types of diseases which can happen in this period if not

managed properly.

Our Acharyas Charaka, Sushruta, both Vaghbhata said what so ever disease

afflict the sutika are difficuilt to cure or become incurable, Ayurveda has advises a

specific diet and life style regime called sutika paricharya to prevent the

complications and to restore the health of the mother.

The paricharya described in our classics is very essential for the sutika to

regain her bala which has been followed since ancient times.

1] Abhyanga

It can be sthanika (udara, yoni),sarvadaihika with help of ghrta and tailas mentioned

in text are beneficial. It is having list of advantages:

It is jara hara, pushti kara - gives bala to dhatu.

Discussion


Shrama hara-reduces the stress and strain of the muscles due to excessive stretching

during labour,weigth bearing and uterine contractions.

Vata hara,klesha sahatwa, abhigata sahatwa, dhadyakritha67

i.e helps strengthen the

sutika to tolerate the effects strenuous labour.

Abhyanga of lower back help for proper drainage lochia. Yoni abhyanga tones up

the vagina and perineum and prevents laxity and prolapse, alleviates pains , heals

vaginal and perineal wounds42

2] Parisheka and Avagaha20

Parisheka is pouring hot water in a stream , it is vatakapha hara, vedana hara, does

agni dipti, twak prasadana, sroto nirmalata so that the abnormal blood clots

accumulated in the uterine cavity after delivery is excreated properly and vata dosha

subsides.

3] Udara veshtana (Pattabandhana)

It prevents vitiation of vata dosha by compressing the hollow space produced after

expulsion of the fetus.Abdomen should be tightly wrapped with long cotton cloth

after bath.It provides support to the back and abdomen.It mainly helps the uterus to

shrink back to its normal size.

4] Yonidhupana

Vaginal defence is lowered due to hypoestrogenic state and patient is prone to

infection.Dhupana will maintain the hygiene of the perineum.It keeps the episiotomy

wound healthy and hastens its healing process.The drugs having jantugna , kandugna ,

vrana ropana and shodhana properties are been used for the purpose.

Discussion


In the same way puerperial after pains can be relieved off by following the

above paricharya and some home remedies such as Ginger tea, Fennel tea, rice water,

warm water bath and oil massage along with the given medications.

DISCUSION ON THE DRUGS

Almost all the drugs in the group have ushna veerya, katu vipak,laghu ruksha

teekshna gunas and kaphavata hara properties.

Probable mode of action of the drugs

After pains is predominant feature of vata dosha,the sutika having taken the

Bharangyadi kalka and shuddha hingu having ingriedients which have vata hara,sula

hara, shoths hara,vedanasthapana properties.

Katu rasa, laghu ruksha,teekshna guna and ushna veerya of Bharangi etc drugs

will help improve the metabolic rate thereby increasing the agni which helps the

sutika to take congenial diet which will provide the necessary nutrients to all organs

of the body.The drugs having anti oxidant properties by which the puerperial women

regains her strength thus have proper sthanya utpatti and vriddhi as it is also having

sthanya shodhaka properties.As the women regains her bala ,she will have better

threshold of pain.

The karma like shotha hara, vedanasthapana, garbhashaya shodhana, rakta

shodhana,sthanya shodana,anulomana soola hara of bharangi etc rugs relives the

spasmodic contaction establishes good uterine contraction and retraction which

favors proper involution of uterus and normalizes the lochial discharge,therby

stabilizes or prevents the pains (After Pains).

Discussion


Good Involution of the uterus and proper lochial discharge ensures the sroto

shuddhi which results in koshta shuddhi, Bharangyadi kalka helps in stimulating the

metabolism of the body and excreation of the waste products by its anulomana

properties, thus relieving the pain.

Bharangi, the drug having kaphavata shamaka, shotha hara, vranapacana, rakta

shodhana, anulomana will help in the healing process of episiotomy wound, helps

excreation of lochial discharge by anuloma & rakta shodhaka activity as a result the

pain is relieved.Bharangi-Clerodendrum serratum is having serratogenic acid,

phytoserols,saponins etc acts as anti bacterial, anti allergic stomachic48

hence reduces

the infection of puerperial women.

It has been observed that the Nagara one among the ingriedients of

Bharangyadi Kalka is not having anti inflammatory, hypolipidaemia, antibacterial,

analgesia but also have anti oxidant along with anti thrombolytic activity50

,

thrombosis of leg is commonly seen in post delivered ladies hence this ailment

isprevented by the presence of the drug Nagara.

Nagara-Ginger-The gingerols present in dried ginger has a very powerful anti

inflammatory properties which helps in decreasing the level of pain, also having

thermogenic activity which helps lower the body temperature and treats the cold and

flu and gets rid of toxins in sutika who is prone to such ailments in puerperial period.

Devadaru having the properties of vedana sthapana, shotha hara, garbhashaya

shodhaka, anuloma49

etc helps in relieving the pain ailment and also promotes good

uterine activity by cleansing the uterus of its unwanted contents therby good lochial

discharge and involution of uterus is possible with this drug.

Discussion


Devadaru-Cedrus Deodar is having the activities such as anti

inflammatory,anti bacterial,anti septic and analgesia51

by which the ailments is

subsided along with regaining good health of the puerperial women as she will be

protected against the infection prone during the post partum period.

Hingu-having the katu rasa, laghu teekshna guna, ushna veerya is useful in

flatulent colic vitiated conditions of vata kapha dosha having vedana sthapana, sula

hara,vata hara anulomana47

helping in relieving the pain(Makkalla). As Hingu is

having all these qualities, so it is advised to administer with ghrita only to make it

palatable and to reduce its teekshnata.

Hingu-Ferula Asafetida was reported to have anti spasmodic, abortifacient

emmmanagogue, anti bacterial etc activities useful in conditons of udara shoola,

hridya shoola, agnimandya, basti shoola etc which are the predominant complaints of

the sutika makalla.

भषैज्यं ििगणुऽेपाने भोजनाग्रे प्रशस्यते ।

- शा.सं.पिूव

Here the drug is given before i.e. pragbhakta because as there is vitiation of

Apanavata.

DISCUSSION ON THE PATIENTS

All the patients had attended complete follow ups and there were no dropouts in

the study.

The study has been carried out in 30 delivered ladies, considering the most

common ailments seen after delivery that the lady experiences.The clinical study or

the medications prescribed will be considered effective only if the lady gets relief

Discussion


from the complaints.With this view the present study was selected which showed

improvements in both the groups.

Drugs were selected on the basis of their properties and actions to treat the

ailments described.To evaluate the efficacy and to compare the effect of the drugs i.e

Bharangyadi Kalka and Shuddha Hingu,the 30 patients were divided into 2 groups of

15 patients each,Group A was given the drug Bharangyadi Kalka in the dose of 6

gms bd before food for 5 days and Group B was given Shuddha Hingu in the dose of

125 mg bd before food for 5 days and the groups were followed up on day 6,15 and

30 of the treatment.

DISSCUSION ON OBSERVATION SEEN IN PATIENTS

AGE-Among the 30 patients included in the study, 26.7% were in the age group of

18-20 yrs, 43.3% of the patients were in the age group of 21-25 yrs, 30% of the

patients were in the age group of 26-30 yrs.The age group between 20-35 is the

average child bearing period for primi as well as for multi.The age group between 18-

25 is considered for marriage and conceiving soon after.

EDUCATION- Among the 30 patients included in the study 23.3% of the patients

were illiterate, 36.7% of the patients studied SSLC, 26.7% of the patients were

studied PUC,13.3% of the patients were graduate, this shows that majority of the

patients were literate as far as education is concerned.

OCCUPATION- Among the 30 patients included in study 96 % of the patients were

housewife, 3.3% of the patients were office goers, this shows that the majority of the

patients were housewife doing their daily household works.

Discussion


SOCIAL STATUS- Among the 30 patients included in the study 36.7% of the

patients were of lower class, 46.7% of the patients were of middle class,16.7% of the

patients were of high class. The status of the patients shows that they were aware of

the need of hospital delivery and its managements of conditions.

RELIGION- Among the 30 patients included in the study 83.3% of the patients were

Hindu, 16.7% of the patients were Muslims.This shows that area of study was more

Hindu dominating population.

OBSTETRIC HISTORY- Among the 30 patients include in the study 50% of the

patients were primi, whereas 50% of the patients were multi.

DIET-Among the 30 patients included in the study 60% of the patients were

habituated to take mixed diet, 40% of the patients were vegetarians.It can be stated as

the patients in the area were habituated to take mixed diet.

PRAKRUTI- Among the 30 patients included in the study 40%of the patients were

of VP Prakruti, 30%of the patients were of V Prakruti,16.7% of the patients were VK

prakruti and 13.3% of the patients were of P prakruti.

Discussion


DISCUSSION ON THE EFFECT OF TREATMENT

UDAARA SHOOLA

Group A-On stastically analyzing the effect of treatment on Udara shoola it was

noted that there was statistically significant change.The mean score of udara shola of

which was 40% in No pain grade,33.3% were in Mild pian grade,-46.7% were in

Moderate pain grade,-26.7% were in Severe pain grade.

Group B- On stastically analyzing the effect of treatment on Udara shoola it was

noted that there was statistically significant change.The mean score of which was

73.3% in No pain grade,-6.6% were in Mild pain grade,-46.7% were in Moderate pain

grade,-20.0% were in Severe pain grade.

It was observed that there was significant difference (P=0.006) between group

B(73.3%) and group A(40%) which shows that the drug Shuddha Hingu may be

having vata hara property,thus this statement is also justified by Dr.Gyan Kamat et al

saying that Hingu acts as anti spasmodic.This could be due to the properties of hingu

as anulomana, shoola hara, vedana sthapana which helped in relieving the pain.

The mean difference of udara shoola in Group A was reduced from 2.00 ± 0.76 to

0.60 ± 0.51 on D30. And in Group B it was reduced from 1.87 ± 0.74 to 0.27 ± 0.46

on D30.

The difference in the mean values of the two groups shows that it is statistically

significant (P=0.070+).

Incidence of lower abdominal pain in women after delivery is one of the most

common problem today. After labour and birth there may be pain or soreness in the

Discussion


whole body. It happens because of laboring in different positions and pushing. Body

undergoes tremendous changes throughout the nine months of pregnancy and in just

six week afterwards organs return to their normal or previous state, during this

process a few transformation may cause discomfort to the body. In this study the said

parameter is considered and the desired effect has been shown in both the groups. The

drugs of study groups having properties like shula prasamana, vedana sthapana, vata

hara, shotha hara, garbhashaya shodhana etc, have shown results in reducing the pain

parameter, the drug Hingu has showed better results than the Bharangyadi Kalka .

STANYA PRAVARTANA

Group A- On statistically analyzing the effect on treatment on Stanya pravartana it

was noted that there was no significant change.The mean score of stanya pravartana

of which was-33.3% in absent grade, -60% in inadequate grade, 93.3% in adequate

grade, 0.0% in excessive grade.

Group B-On statistically analyzing the effect of treatment on stanya pravartana it was

noted that there was no significant change.The mean score of which was -33.3% in

absent grade, -66.7% in inadequate grade, 100% in adequate, 0.0% in excessive grade.

The mean difference of stanya pravartana in group A was increased from0.73 ± 0.59

to2.00 ± 0.00 on D30 And in group B it was increased from 0.67 ± 0.49 to2.00 ± 0.00

on D30.

There is not a statistically significant difference between the input groups(P=1.000).It

can be stated that the drugs of treatment groups may not be acting on stanya

pravartana thus it can be stated that it is one of physiology change in peuerperium.

Discussion


Establishment of lactation is one of the important measures in the management of the

puerperiumThe sthanya uttpatti and vriddhi depends on the nutrition of the sutika as

also mentioned in classics about the aahara etc paricharya to be followed in this

period for proper nourishment of the dhatus.Formation of proper rasa dhatu by means

of aahara favours the formation of breast milk which the updhatu of rasa dhatu.The

study of drugs having deepana pacana activity will help to increase the agni thus the

mother takes nutritious diet will improve the general condition of the mother,thus will

have proper lactation.In the study there was no undue complications like breast

engorgement, mastitis, abcess etc. Desired results were not statistically significant in

both the groups in lactation parameter.

INVOLUTION OF UTERUS

Group A- On statistically analyzing the effect of treatment on involution of uterus it

was noted that there was no statistically significant change.The mean score of

involution of uterus which was -99.3% in No involution grade, -6.7% in 0-1.25 cms

involution grade, 0.0% in 1.25-5 cms involution grade,0.0% in 5-10 cms involution

grade,0.0% in 10-13.5 cms involution grade,100% in completelety involuted grade.

Group B-On On statistically analyzing the effect of treatment on involution of uterus

it was noted that there was no statistically significant change. The mean score of

involution of uterus which was -100% in No involution grade, 0.0% in 0-1.25 cms

involution grade, 0.0% in1.25-5 cms involution grade, 0.0% in 5-10 cms involution

grade,0.0% in 10-13.5 cms involution grade, 100% in completely involuted grade.

The difference in the mean values in group A was increased from 0.07 ± 0.26 to 5.00

± 0.00 on D30 and in group B it was increased from 0.67 ± 0.90 to 5.00 ± 0.00 on

D30.

Discussion


There is not a statistically significant difference between the input groups (P=1.000).

Good contractions of the uterus after delivery as it returns to its pre-pregnant size, the

process called as involution is the significant change in the lady who has given

birth.Process of involution is affected by many factors such as multiparity,

overdistended uterus due to big baby, polyhydraminous etc which may take some

more time than the normal to revert back to its original size. Also retained products of

after births may have adverse effect on the general condition of the mother leading to

infection or PPH where the puerperial lady is prone to during this period of

postpartum.Here the process of involution has occurred in normal pace in both the

groups. The drugs in Bharangyadi Kalka having ushna, teekshna, garbhashaya

shodhaka, rakta shodhaka, stanyashodhaka helped relieved the spasmodic contractions

and established good uterine retraction and contractions have favoured proper

involution but not significant.

LOCHIA

Group A-On statistically analyzing the effect of treatment on lochial bleeding it was

noted that there was no statistically significant change .The mean score of lochia



grade.

Group B- On statistically analyzing the effect of treatment on lochial bleeding it was

noted that there was no statistically significant change. The mean score of lochia


Discussion



grade.

The mean difference of Lochia in Group A was decreased from 3.40 ± 0.51 to 0.67 ±

0.98 on D30 and in Group B it was decreased from 3.33 ± 0.49 to 1.27 ± 1.33.

There is not a statistically significant difference between the input groups(P=0.194).

Early in puerperium, sloughing of decidual tissue results in a vaginal

discharge of variable quantity, is termed as lochia . Conventional obstetrical wisdom

shas for many years taught that lochia lasts for approx. 2 weeks after delivery. Recent

studies, however have indicated that lochia persists for upto 4 weeks and may stop

and resume up to 56 days after delivery. Both the groups showed no results in

normalizing the lochial discharge . The lochial discharge result was not significant

though the drugs having teekshna, ushna guna, katurasa ushna virya, vatanuloma,

garbhashaya shodhaka properties of drugs used.

OTHER OBSERVATIONS SEEN DURING TRIALS

One patient in group A had gap in episiotomy wound during the follow up

period. On examination it was found that the patient had unhygienic condition.

On history taking it was noted that patient had constipation due to which there

was straining during defecation which resulted in the gap in the wound. The

wound was healed by daily dressing only. Though th drug has no effect on

episiotomy.

Abdominal girth : It was observed that there was decrease in the abdominal

girth from the day of trial to the follow up. In some it was observed that there

Discussion


was increase in the abdominal girth during the follow up periods. This could

be due to fat accumulation during the time of sutika paricharya.

Conclusion


CONCLUSION

Since After pains can lead to the pain in nervous hormonal stress responses

which prohibit the mother from performing daily tasks and due to fact that pregnancy

and puerperium period is verey important in fetal, maternal, and infant

health,suppertive care should be developed for this period to improve the relationship

between the mother and the infant and to reduce the side effects.Therefore mothers

support and follow up during this period is essential.Cosidering the importance of

health promotion,protection of women,the high incidence and prevalence of after

pains and the need to investigate the related factor,hoping that the results of this study

trigger the conduction of high quality clinical and non-invasive services and

encourage taking a step towards improving the health and satisfaction of the women

in the society.

The study has shown good results over relieving the pain ,healing the

episotomy wound,giving strength to the lady by increasing the appetite,clearing the

bowels etc,therby having proper lactation,involution of the uterus and shedding of

lochia.

As the drug Hingu showed better results which was administered in group B than

Bharangyadi kalka which was administered in group A, hence the hypothesis H2 can

be accepted i.e.

H2 : There is significant effect of Shuddha Hingu than Bharangyadi kalka in Sutika

Makkalla.

Conclusion


Considering that longer duration of breast feeding and ambulation in early postpartum

period could decrease after pains,it is suggested to encourage postpartum mothers to

begin breast feeding and ambulation as soon as possible after the birth of the child.

Scope for further research

Further studies in the same topic can be carried out in large sample for better results,

since the sample here is too small.

Further scope of research in the following topic can be carried out by taking more

factors and studying each factor to see the results with larger samples.

The dose of the drug Hingu taken was very less i.e. 125 mg BD. This dose is taken in

the view that it should not interfere in the normal lactation. As this dose did not affect

lactation, so further study can be taken with a larger dose.

The dose of the drug bharangyadi kalka to be reduced as the dose taken here is 6 gms

BD where there was difficulty for the patients to take and also by making it in

palatable form.

Summary


SUMMARY

The dissertation entitled “A COMPARATIVE CLINICAL STUDY OF

BHARANGYADI AND SHUDHA HINGU IN SUTIKA MAKKALLA WITH

RESPECTIVE TO PUERPERAL AFTER PAINS” is been discussed under

headings namely review of literature, Methodology, observation, Results , discussion

and conclusion.

Introduction

Now days the post partum and post natal period receives less attention apart

from pregnancy and child birth as a result of which the Sutika complaints of various

aliment such as low abdominal pain, backache weakness, body ache and even

psychological instability is seen. To fulfill her responsibilities she needs to be free

from aliments, in order to promote healthy puerperium that is maternal health so as to

resume her normal activities as soon as possible, hence the present study has been

selected.


Historical review : Has been dealt with the origin and reference of Sutika and

Sutika Vyadhi from beginning of Vedic Period.

Sutika Paricharaya, Sutika vyadhi : Ayurvedic review Sutika and its vyadhis

has been understood according to different Acharays, the suitka paribhasha,

paricharya, Kala and sutika vyadhi have been dealt

Summary


Puerperium after pains : Modern review of puerperium with different stages,

hormonal and systemic changes taking place in puerperial period and management of

puerperal after pains have been dealt with.

Drug Review :- The drugs selected for the study have been discussed in detail

according to ayurvedic and modern composition, properties, the action of drugs has

been hypothetically concluded due to laghu, Ruksha, Tikshna gunas, katu, tikta rasa

with a deepana, Pacana, vatanulomana, Vedanasthapna etc., properties doing

garbhashaya shodhan, Rakta Shodhan improving her lochial discharge with good

uterine involution of uterus.

Methodology :

This explains about the method of data collection, inclusion, exclusion criteria

and assessment criteria i.e the study design

Observation:

The observation noted throughout the study process has been included under

this dissertation work done.

Results :

Statistically significance of the study has been incorporated here in one of the

parameter.Study has been found effective in relieving the symptons of pain which was

the most important parameter in this study than the other parameters.It has been seen

that there was improvement in the general condition of the sutika thus proper

involution, lactation, lochial shedding was possible.

Summary


Discussion:

Here along with treatment, the sutika wasadvised the paricharya was

analysed.The mode of action of the Brangyadi Kalka and Shuddha Hingu in the

selected parameters and also discussion on the observation and effect of the treatment

on the patients has been disscussed.

Conclusion:

Conclusion drawn from various section of the work are given in this part of

dissertation. i.e Shuddha Hingu showed better results than Bharangyadi Kalka in the

parametrs of assessment,hence can be advised in Sutika Makkalla.

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Annexure

A comparative clinical study to evaluate the efficacy of Bharangyadi kalka and Shuddha Hingu in the management of Sutika Makkalla w.r.t Puerperal after pains.

Patient’s consent

I am fully educated with the disease and treatment procedure thereby I got satisfied. I

accept for medical trial on me happily.

Date : Signature of Patient

Annexure


Mahantesh Ayurvedic Medical College, Ilkal

Affliated of RGUHS, Karnataka, Bangalore.

Department of Post Graduate Studies in PTSR

A Comparative Clinical Study to evaluate the efficacy of

Bharangyadi Kalka and Shuddha Hingu in Management of Sutika

Makkalla w.r.t Puerperal After Pains

Guide – Dr.S.B.Nadagouda (M.S Ayu) Scholar- Dr. Boradevi Hungund

Professor Dept. of PTSR

CASE SHEET PERFORMA

Name: Case:

Husband / Father Name: IPD:

Address: OPD:

Age:

Sex: Female DOA:

Education: Illiterate/SSLC/PUC/Graduation. DOD:

Occupation: Student/HW/Off Job/ Business.

Religion : Hindu/ Muslim / Christian.

Socioecomic Status: Lower/ Middle/Highclass.

Email/Phone No:

Date of Commencement of Treatment:

Date of Completion:

Result:

Patient’s consent

I am fully educated with the disease and treatment procedure thereby I got satisfied. I

accept for medical trial on me happily.

Date : Signature of Patient

Annexure


1] Pradhana Vedana [chief complaints with duration] :

2] Poorva Vyadhi Vrittanta [h/o. Past illness/surgery] :

3] Kula Vrittanta [family History] :

4] Vaiyaktika Vrittanta :

Appetite : good/ moderate/ poor

Diet : Veg/ Mixed

Sleep : Normal/ Disturbed

Bowel : Regular/Irregular

Micturation : Regular/ Irregular

Habits :

5] Rajo – Vrittanta :

Age of Menarche :

Menstrual Cycle : Regular / Irregular

LMP :

EDD :

Annexure


6] Poorva Prasava Vrittanta [Obstetric history] :

No. Yrs Date Pregnancy

event

Labour

event

Method of

Delivery

Puerperium Baby

7] Prasava Vrittanta (Delivery Notes) :

8] Pareeksha [Examination] :

A] Samanya Pareeksha [General Examination] :

1] Dasavidha Pareeksha :

1. Prakriti : V/P/K/VP/VK/PK/VPK.

2. Vikriti : V/P/K

3. Sara : P/M/A

4. Samhanana : P/M/A

5. Pramana : Heena/Madhyama/ Uttam

6. Satmya : Ekarasa/ Sarvarasa

7. Satva : Pravara/ Madhyama/ Avara

8. Ahara Shakti : P/M/A

9. Vyayama Shakti : P/M/A

10. Vayah : Baala/ Madhyam/Vruddha

2] Ashtavidha Pareeksha :

Nadi : Shadha:

Mala : Sparsha:

Mutra : Drika:

Jihwa : Akruti:

Annexure


3] Vital Signs :

Pulse : Blood Pressure:

Temperature : Height:

Respiration Rate : Weight:

B] Samsthanika Pareekhsa ( Systemic Examination) :

1. R.S :

2. C.V.S :

3. C.N.S :

C] Sthanika Pareeksha ( Local Examination) :

P/A :

9] Prayogika Pareksha :

CBC :

HIV :

HBsAg :

RBS :

VDRL :

Annexure


10] Assessment Criteria :

Subjective Parameter

Pain abdomen ( Gradings)

Grade BT AT (6th

day) AT (15th

day) AT (30th

day)

0 – No pain

1 – Mild pain

2 – Mod pain

3 – Severe pain

Objective Parameter

P/A Uteine Inrvolution

Fundal ht

in cms

Day 1 Day 2 Day 3 Day 4 Day 5

Follow up

Fundal ht

in cms

Day 6 Day 15 Day 30

Effect of Drug on P/V Bleeding

P/V

Bleeding


Follow up

P/V

Bleeding

Day 6 Day 15 Day 30

Annexure


Effect of Drug on Stanya

Stanya


Follow up

Stanya

Day 6 Day 15 Day 30

11] Chikista :

Date of Treatment schedule initiation –

Date of Completion of Treatment –

Group A Bharangyadi Kalka

Days Time Dose Any Complication Observation

1st day

2nd

day

3rd

day

4th

day

5th

day

Date of Treatment schedule initiation – Date of Completion of Treatment –

Group B Shuddha Hingu

Days Time Dose Any Complication

Observation

1st day

2nd day

3rd day

4th day

5th day

Annexure


12] Follow up

6th

day :

15th

day :

30th

day :

13] Result : 1) Cured

2) Improved

3) Unchanged

14] Conclusion

Signature of Guide Signature of Researcher

(Dr. S. B. Nadagouda) (Dr. Boradevi. B. Hungund)



THE DRUGS OF BHARANGYADI KALKA



HINGU



PREPARED BHARANGYADI KALKA



HINGU POWDER

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