Lacerations seevana psr

“CLINICAL STUDY ON UTILITY OF DIFFERENT TYPES

OF SEEVANA KARMA IN EPISIOTOMY,

LACERATIONS OF GENITAL TRACT”

By

PRATHIMA. B. A. M. S.

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Karnataka, Bangalore

In partial fulfillment

Of the requirements for the degree of

MASTER OF SURGERY (Ayu) In

PRASOOTI TANTRA AND STREEROGA

S. D. M. COLLEGE OF AYURVEDA, UDUPI

2010 - 2011

GUIDE

Dr. USHA.V.N.K., M.D. (Ayu)

Professor & H.O.D.,

S. D. M. C. A., Udupi

CO-GUIDE

Dr. SUCHETHA., M.D. (Ayu)

Lecturer,


RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

This is to certify that the dissertation entitled “CLINICAL STUDY ON UTILITY OF

DIFFERENT TYPES OF SEEVANA KARMA IN EPISIOTOMY,

LACERATIONS OF GENITAL TRACT” is a bonafide research work done by

Dr. Prathima in partial fulfillment of the requirement for the degree of M.S. (Ayu) in

Prasooti Tantra and Stree roga.

Date:

Place: Udupi

GUIDE

Dr. Usha. V.N.K. M.D. (AYU)

Professor & H.O.D.,


CERTIFICATE BY THE GUIDE

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE

I hereby declare that this dissertation entitled “CLINICAL STUDY ON UTILITY OF


LACERATIONS OF GENITAL TRACT” is a bonafide and genuine research work

carried by me under the guidance of Dr. V.N.K. Usha. Professor, H.O.D, and

co-guidance of Dr. Suchetha Kumari, Lecturer, Dept. of Prasooti Tantra and Stree roga,

S.D.M.college of Ayurveda, Udupi.

Date: Dr. Prathima

Place: Udupi B.A.M.S.

DECLARATION

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

This is to certify that the dissertation entitled “CLINICAL STUDY OF UTILITY OF


LACERATIONS OF GENITAL TRACT” is a bonafide research work done by

Dr. Prathima in partial fulfillment of the requirement for the degree of M.S. (Ayu) in

Prasooti Tantra and Stree Roga.

Date:

Place: Udupi

CO-GUIDE

Dr.SUCHETHA, M.D. (Ayu)

Lecturer,


CERTIFICATE BY THE CO GUIDE


This is to certify that the dissertation entitled “CLINICAL STUDY ON UTILITY OF

DIFFERENT TYPES SEEVANAKARM IN EPISIOTOMY, LACERATIONS OF

GENITAL TRACT” is a bonafide research work done by Dr. Prathima under the

guidance of Dr. V.N.K. Usha, Professor, H.O.D. and co guidance of

Dr. Suchetha, Lecturer, Dept.of Prasooti Tantra and Stree Roga, S. D. M. College of

Ayurveda, Udupi.

.

H. O. D.

Dr.V.N.K.Usha

Dept. of Prasooti Tantra and Stree roga

S.D.M.C.A. Udupi

PRINCIPAL

Dr. U.N.PRASAD (M.D.Ayu)

S.D.M.C.A. Udupi

Date:

Place: Udupi

ENDORSEMENT


I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shall

have the rights to preserve, use and disseminate this dissertation/ thesis in print or

electronic format for academic / research purpose.

Date: Dr. Prathima

Place: Udupi B.A.M.S.

COPY RIGHT

Acknowledgement

ACKNOWLEDGEMENT

Completion of dissertation work is the hallmark in postgraduate studies.At this junction my

head bows down with great humility in the feet of almighty, without inspiration,I would not

have been able to attain these stages in my life.

At the same time, it gives me immense pleasure to remember my respected parents Mr.N.Prem

kumar, and Mrs. Bharathi and Grandmother Mrs. Lalithamma for showering their blessings

and giving me moral support and guidance throughout the study.

It is indeed my fortune to have carried out this dissertation work at S.D.M. college of

Ayurveda,Udupi. In this regard, I would like to express my heartfelt gratitude to honourable

Dr.D.Veerendra Hegde, Dharmadhikari, Shri kshetra Dharmasthala, and president of S.D.M.

Society

I genuinely feel that any words of gratitude are not sufficient to express my humble thanks to

my proficient guide Dr.V.N.K.Usha, Professor and HOD of Dept. of Prasooti tantra and

Streeroga, SDM College of Ayurveda. Her excellent guidance, moral support & suggestions

during my course of a study gave me a way to success for the dissertation in all aspects.

I take this opportunity to thank my Co-guide Dr.Suchetha for all advice & suggestions during

the course of my work.

My sincere gratitude & thanks to Dr.Mamatha K.V.,Asst.professor, Dept. of Prasooti tantra

and Streeroga, SDM College of Ayurveda,Kuthpady , for her suggestions.

My sincere gratitude & thanks to Dr.Ramadevi G.Asst.professor, Dept. of Prasooti tantra

and Streeroga, SDM College of Ayurveda,Kuthpady , for her suggestions.

I express my regards to Dr.Vidya Ballal for her suggestions and help.

Acknowledgement

I am greatful to Dr.U.N.Prasad, Principal,S.D.M. College for his invaluable support and

guidance for the completion of this thesies.

My deep sense of gratitude to Dr.Govinda Raju Dean of P.G. Studies and Dr.Prabhakar

Renjol Co- Dean of P.G.studies for their valuable guidance.

I am thankful to Dr.Y.N.Shetty,Medical Superintendent and Mr.C.S. Hegde,Manager,

S.D.M. Ayurvedic Hospital, Udupi,for providing all the facilities in the hospital for my study.

I express my regards to Dr.Krishna Bai and Dr.Veena Mayya for their help.

I greately indebted to Dr.Muralidhar Sharma,Dept.of Shalya tantra, for his ablest guidance.

I extend my regard to Mr.Harish Bhat ,Librarian, S.D.M. College of Ayurveda,udupi for his

generous help during the course of my life.

I express my deep gratitude to my friends Dr.Deepashree, Dr. Padmasarita, Dr.Rekha, Dr.

Rachana and Dr. Sunita, Dr.Girija whose presence gave me encouragement and support

throughout my study.

I thank all those who have directly or indirectly contributed to the successful completion of this

work, still I apologize for errata and shortcomings.

Dr.Prathima

Dedica

ted to

my

parents

LIST OF ABBREVIATIONS

A.S. – Astanga Sangraha

Su.Sa. – Sushrutha Samhita

A.H. – Astanga Hridaya

& _ and

% _ Percentage

No. _ Number of patients

Pt. _ Patients

ABSTRACT

Title: “Clinical study on utility of different types of seevana karma in episiotomy,

lacerations of genital tract”.

Background: Restoring Ayurvedic surgical terminology which was described centuries before

can create self reliance in practicing surgical techniques and for planning further surgical

procedures. The process of delivery can be made easy by yoniprasarana (dilating vulval orifice),

by surgical intervention Utkartana karma which was forwarded as an established surgical

practice. In contemporary age, the “Episiotomy” is performed to cut short the second stage of

labour and to decrease the trauma to the vaginal tissue. For repairing these wounds different

seevana karma are mentioned in our classics. Aghata, Abhigata & Utkartana require seevana. A

good suturing procedure immediately ensures haemostasis, healthy healing, prevents infection

and in long run preserves the integrity of the pelvic floor. Seevana karma is one among the

Astavidha shastra Karmas described in classics. There are four types of seevana karma

mentioned in classics with its indication i.e. Vellitaka, Gophanika, Tunnasevani & Rujugranthi.

Hence the present study is carried out for evaluating the efficacy of different types of seevana

karma in episiotomy, lacerations of genital tract.

Objective:

• Conceptual study on utility of Ashtavidha shastra karma in prasoothi tantra &

stree roga.

• Conceptual study of seevana karma with its classification & method of its

application.

• Analysis of different types of seevana karma in repairing of episiotomy,

lacerations of genital tract.

Design and setting: it is a descriptive observational study. Randomly 50 patients selected from

IPD of S.D.M. Ayurveda hospital, Kuthpady, Udupi, according to inclusive criteria were

registered for the study. The seevana vidhi is observed with results & the utility of seevana vidhi

is evaluated.

Results:

• 70% patients underwent episiotomy, different layers of episiotomy are sutured by

different suturing techniques. For suturing mucosal layer Vellitaka (continuous suture)

opted,

• For suturing muscle layer, 74% patient undergone Rujugranthi (interrupted suture) &

26% undergone Vellitaka (continuous suture)

• For suturing skin, 78% patients undergone Rujugranthi (mattress suture, a variety of

interrupted suture) & 22% having Tunnasevani (subcuticular suture).

• 12% perineal tear observed & sutured by Rujugranthi (interrupted suture).

• 14% cervical tear and 4% vaginal tear sutured by Rujugranthi (interrupted suture).

Conclusion:

Gophanika by its nature of intermittent interlocking gives all the comforts provided by

vellitaka and at the same time it is secured because of its interlocking.

For suturing skin, compared to Rujugranthi, in Tunnasevani pain is less; discomfort to the

patient is minimal and left with fine scar within 15 days. In all patients healing was good.

Keywords: Seevana karma, Utkartana, Vrana, Episiotomy

CONTENTS

CHAPTER NO.

TITLE

PAGE NO.

1.

Introduction

1-2

2.

Objectives of the study

3

Conceptual study

3.1 Historical review. 4-7

3.2 Introduction of shastra karma 8-9

3.3 seevana karma 10-16

3.4 Anatomy 17-22

3.

3.5

Disease review 23-34

Clinical study

4.1 Materials and Methods 35-36

4. 4.2 Observations 37-64 5

Discussion

65-70

6

Summary and conclusion

71-73

7

Bibliography

74-80

8

Annexure

81-84

LIST OF FIGURES

Serial no.

Name of picture

Page no.

1.

Vritta Shastrakarma

11

2.

Trayasra Shastrakarma

11

3.

Rujugranthi seevana karma

15

4.

Vellitaka Seevana karma

15

5.

Tunnasevani Seevana karma

15

6.

Performing Episiotomy

29

7.

Suturing of layers

29

LIST OF GRAPHS

GRAPH NO

LIST OF GRAPHS

PAGE NO.

1.

Distribution acc. to Age

37

2.

Distribution acc. to Religion

38

3.

Distribution acc. to S-E status

39

4.

Distribution acc. to Occupation

40

5.

Distribution acc. to Region

41

6.

Distribution acc. to Education

42

7.

Distribution acc. to Parity

43

8.

Distribution acc. to Diet

44

9.

Distribution acc. to Prakruthi

45

10.

Distribution acc. to Saara

46

11.

Distribution acc. to Sattva

47

12.

Distribution acc. to Samhanana

48

13.

Distribution acc.to Satmya

49

14.

Distribution acc.to Aharashak..

50

15.

Distribution acc. to Vyayamash.

51

16.

Incidence of suturing in skin

52

17.

Incidence of suturing in muscle

53

18.

Incidence of suturing in Mucous

54

19.

Incidence of suturing tech.in lacerat

55

20.

Incidence of complication

56

21.

Incidence of haemotoma

57

22.

Intensity of pain

60

23.

Incidence of Resuturing

61

24.

Incidence of suture absorption

62

25.

Incidence of wound healing on 15th

63

26


64

LIST OF TABLES

TABLE NO.

LIST OF TABLES

PAGE NO.

1.

Astavidha shastra karma

8

2.

Merits and demerits

27

3.

Distribution acc.to Age

37

4.

Distribution acc. to Religion

38

5.

Distribution acc. to S-E status

39

6.

Distribution acc. to Occupation

40

7.

Distribution acc. to Region

41

8.

Distribution acc. to Education

42

9.

Distribution acc. to Parity

43

10.

Distribution acc. to Diet

44

11.

Distribution acc. to Prakruthi

45

12.

Distribution acc. to Saara

46

13.

Distribution acc. to Sattva

47

14.

Distribution acc. to Samhanana

48

15.

Distribution acc. to Satmya

49

16.

Distribution acc. to Aharashakti

50

17.

Distribution acc. to Vyayamshakti

51

18.

Suturing pattern in Skin

52

19.

Suturing pattern in Muscle

53

20.

Suturing pattern in Mucous

54

21.

Suturing pattern in Lacerations

55

22.

Complication of suturing tech.

56

23.

Distribution of pt in Haemotoma

57

24.

Intensity of pain on day1

58

25.

Intensity of pain on day 2

58

26.


59

27.


59

28.


60

29.

Incidence of Resuturing of wound

61

30.

Incidence of suture absorption

62

31.

Incidence of wound healing 15th day

63

32.


64.

Chapter 1 Introduction

1 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract

INTRODUCTION

Ayurveda is the science of life, it is eternal (Saswata) due to, no beginnining (Anadi),

deals with such things which are inherent in nature (Nitya). Ayurveda is not only rich in

medicine but is enriched in surgical field too.

Acharya Sushrutha is the epitome of ancient Indian surgery which expounds the

concepts and skill in surgery prevalent at that time. He has explained about basic principles of

surgery, surgical procedures etc. upto the plastic surgery hence known as Father of Surgery. He

explained 101 instruments in details; same are used in modified form in present era.

Prasava dharma in a woman is an inherent factor of prakruthi. The process of delivery,

can be made easier by various procedures one of that being Yoniprasarana, dilating the vulval

orifice (A.S) 1. One such surgical intervention is Utkartana karma mentioned in Mudhagarbha

chikitsa (Su.sa.) 2 which describes about an incision on muladhara peetha.

In contemporary age the aptitude of obstetrician to opt for methodical incision &

effective repair than ineffective suturing of irregular tears, has given origin to concept of

episiotomy, to cut short the second stage of labour to decrease the trauma to the vaginal tissue,

and expediate delivery of the baby when delivery is a necessary.

After performing episiotomy it is inevitable to suture this wound, so also in lacerations of

various parts that occur during delivery. Various degrees of tears involving maternal passage

may cause immediate complications like haemorrhage, infection, wound dehiscence & remote

complications like urine incontinence, prolapse of organs.

Chapter 1 Introduction


Seevana karma is one of the Shastra karma mentioned by Caraka, Sushrutha &

Vagbhata. Acharya Sushruta has mentioned 4 different types of seevana karma along with its

indication, contraindication, suture material & procedure in detail. Restoring Ayurvedic

terminology which was described centuries before, in routine contemporary practical

interventions can cause self reliance in surgical practice and planning further surgical

procedures.

Hence present study of “evaluating efficacy of different types of Seevana karma in repair

of episiotomy, lacerations of genital tract” has been planned.

Chapter 2 objectives


OBJECTIVES OF THE STUDY

• Conceptual study on utility of Ashtavidha shastra karma in Prasooti tantra & Stree roga.

• Conceptual study of seevana karma with its classification & method of its application.

• Analysis of different types of seevana karma in repairing of Episiotomy, Lacerations of

genital tract.

Chapter 3.1 Historical review


HISTORICAL REVIEW

Preservation of health has been instinctive necessity of mankind from the beginning of

creation. So, Acharya Charaka has said, Ayurveda as beginingless and eternal. Acharya

Sushrutha going further says that creator has delivered it even before creation.3

The history of sutures begins more than 2,000 years ago with the first records of eyed

needles.

In 30 AD, the Roman Celsus again described the use of sutures and clips, and Galen

further described the use of silk and catgut in 150 AD. Description of ligatures used for

haemostasis, used both continuous and simple sutures.

The oldest known suture in the world on Mummy’s abdomen mentioned 1100 BC ago.

Before the end of the first millennium, Avicenna described monofilament with the use of

pig bristles in infected wounds. Surgical and suture technique evolved in the late 1800s with the

development of sterilization procedures. Finally, modern methods created uniformly sized

sutures.

Pre – Vedic period:

Some surgical measures were also practiced is inferred from the findings of trephined

human skulls and curved knives in excavation.4

Vedic period: 5

Surgical operations, such as puncturing of glands, obstetrical operations in women,

treatment of ulcers and wound etc. are also mentioned. There is also sufficient indication to show

that plastic surgery is also performed.



The most popular and expert physicians were twin Ashvins whose marvelous medical and surgical feats described in the Rig-Veda, indicated position of the healing art in that olden days.

Post vedic period:6

Amongst epics and Puranas, Mahabharatha has got references of surgery performed in

obstructed labour.

The Ramayana and Mahabharata and Puranas are valuable treasures and records of Indian

culture, because of their encyclopedic character, contain a lot of information on medicine

prevalence in those days.

In Matsyapurana, abnormalities of delivery and deformity of fetus are mentioned.

Mahavagga, in the book (6) on medicaments, gives valuable information regarding

disease and treatment.

Surgical operation of wounds and abscess were done and they were treated with

bandaging, dusting, fumigation etc.

Jaina tradition mentioned about different types of treatment with its indication. Surgical

operation with sharp instruments, treatment by charmas and drugs were prevalent.

In Kautilya arthashastra, Physicians also accompanied the military expedition, duly

equipped with surgical and other instruments, ointment and dressing materials.

In Agnipurana, invisible agents and surgical wounds are enumerated.

Samhita period:

In Caraka Samhita, chikitsa sthana 25th chapter, mentioned about types of vrana and its

classification, colour of discharge. Later, described about six types of surgical operations7, in this

seevana also one among and mentioned about its indication8.

All operative maneuvers carried out by the present day surgeon involve one or more of

these techniques only and not anything beyond these.



Sushrutha is the first person to evolve and introduce experimental surgery for training

students9. He has described the merits and demerits of all instruments, their proper maintenance

and correct method of use etc, which reflect his expertise.

The Indian plastic surgeon, Sushrutha (AD c380-c450), described suture material made

from flax, hemp, and hair. At that time, the jaws of the black ant were used as surgical clips in

bowel surgery.

In Sushrutha samhita, described about sharp and blunt instruments along with para

surgical measures.

Detailed description about Astavidha shastra karma10 and its indication11,

contraindication12, suture material13 etc. and also it is one of the vrana shasti upakrama14.

In Vagbhata, there is a description about indication15 and contraindication16.

In Bhela samhita, while explaining about chidrodhara and vrana chikitsa, mentioned

about seevana karma17.

Modern view:

Joseph Lister introduced great change in suturing technique. He first attempted

sterilization with the 1860s "carbolic catgut," and chromic catgut followed two decades later.

Sterile catgut was finally achieved in 1906 with iodine treatment.

Production of the first synthetic thread in the early 1930s, which exploded into

production of numerous absorbable and non-absorbable materials.

The first synthetic absorbable was based on polyvinyl alcohol in 1931. Polyesters were

developed in the 1950s, and later the process of radiation sterilization was established for catgut

and polyester. Polyglycolic acid was discovered in the 1960s and implemented in the 1970s.



Although introduced as an obstetric procedure over 200years, earlier, in general,

obstetrician only came to favour episiotomy at the beginning of 20th century18. In the UK today

approximately 50,000 women give birth each year and of these 5, 25,000{70%} will sustain

perineal trauma and will require stitches19.

It was then in 1918 by Pomeroy thought all primigravida should receive an episiotomy to

protect the fetal head and the pelvic floor20.

The majority of the woman will experience perineal pain in the following delivery and

over 100,000 will have a long term problems such as superficial dyspareunia.

By the 1970’, episiotomy rates were high as 90%. Further research carried out over the last 20yrs

has shown in the problems associated with the procedure21.

The WHO recommended an episiotomy rate of 10% for normal deliveries.

Traditionally 3rd and 4th degree perineal tear has been thought to be a complication

affecting relatively small numbers of women.More recent work shown that unrecognized

complete disruption of the anal sphincter is much more common than this long term incontinence

affects 5% of women22.

Chapter 3.2 Introduction of Shastra karma


ASHTAVIDHA SHASTRA KARMA

Acharya sushrutha classified instrument under 2 heading i.e. sharp instrument and blunt

instrument. Blunt instrument used to remove foreign body which is easily available, whereas

sharp instrument were utilized for eight surgical procedures, in different diseases and procedures.

Table no.1

Sushruta Su. 5/5 Charaka Chi. 25/55 Vagbhata Su. 26/28

Chedana Chedana Chedana

Bhedana Patana Bhedana

Lekhana Lekhana Lekhana

Vedhana Vyadhana Vyadhana

Eshana Eshana

Aaharana

Visraavana Prachaana Prachaana

Seevana Seevana Seevana

Utpaatya

Apaatya

Grahana

Kuttana , manthana , dahana

Chapter 3.2 Introduction of Shastra karma


vÉx§É mÉÉrÉlÉ ÌuÉÍkÉ:23

Tempering should be done in 3 ways,

• Alkalies should be used for excising arrow pieces and bone.

• Water should be used for excising, incising and splitting muscles.

• Oil should be used in puncturing veins and excising ligaments.

vÉx§É xÉqmÉiÉç :24

It should be convenient to hold in hand, made up of good metal, must have fine and sharp

edge, and attractive in appearance, all the parts of instrument must be well setup, designed

properly.

vÉx§É SÉãwÉ :25

It should not be blunt, broken, broken blade, too long, unusually short, unusually bulky, and very small.

Chapter 3.4 Anatomy


CERVIX

The cervix is a constricted part of uterus separated from the body by the constriction part

known as the isthamus and behind by the transverse ridge considered as torus uterinus.

This contains a cervical canal, which communicates the uterine cavity with the vagina.

It extends downwards and backwards from the isthamus, protrudes through the anterior

wall of vagina which divides the cervix into supravaginal and vaginal parts.

Structure of the cervix: 42

Serous coat: from the peritoneum which covers the posterior surface of

supravaginal part.

Muscular coat: disposed smooth muscle. Some parts produced from collagenous

and elastic fibrous tissue.

Mucous membrane: by columnar epithelium and stratified squamous epithelium.

Ligaments of cervix: 43

Laterally by a pair of Mackenrodt’s ligaments.

Posteriorly by a pair of uterosacral ligaments.

These ligaments have unstriped muscles and leashes of blood vessels and lymphatic’s.

On each side, the lymphatic drainage into external iliac, obturator lymph nodes, internal iliac

groups and sacral groups.

Chapter 3.4 Anatomy


The vagina

It is the fibromusculo – membranous sheath communicates uterine cavity with exterior at

the vulva.

It extends from the vestibule upwards and backwards upto the vaginal part of the cervix.

Walls – anterior (7cm), posterior (9cm) and 2 lateral walls44.

The lower third, resembles, figure of H, middle third is like transverse slit and upper third

is rounded in shape.

Structures:

Mucous coat: lined by the stratified squamous epithelium without any glands.

Sub mucous layer consists of loose areolar tissue.

Muscular layer consists of inner circular and outer longitudinal.

Fibrous coat from endopelvic fascia.

Arterial supply: 45

Branches of the uterine, vaginal, internal pudendal and middle rectal arteries ------these

together form azygous vaginal arteries.

Venous drainage into internal iliac vein, posterior vaginal wall forms vaginal and superior

rectal veins.

Lymphatic drainage: 46

From upper third – involves uterine artery and drain into internal and external iliac lymph

nodes.

Middle third – from vaginal artery and drainage into internal iliac nodes.

Lower third – drainage into the superficial inguinal lymph nodes.

.

Chapter 3.4 Anatomy


Nerve supply:47

Sympathetic and parasympathetic supply from the pelvic plexus and lower part is by the

pudendal nerve.

Pelvic floor48

• It is a muscular part which separates the pelvic cavity from the anatomical perineum.

• It consists of 3 types of muscle:

Pubococcygeus

Iliococcygeus Levator ani

Ischiococcugeus

• Origin from back of pubic rami from the condensed fascia covering the obturator internus

and from the inner surface of the ischial spine.

• Insertion from midline from before backwards to the vagina, anococcygeal body, lateral

borders of the coccyx and lower part of the sacrum.

Functions:

• To Support the pelvic organs.

• To maintain intra abdominal pressure.

• Facilitations of anterior internal rotation.

• Protection of the perineal body.

Chapter 3.4 Anatomy


The Perineum

It includes all structure which occupies the pelvic outlet and lie below the pelvic

diaphragm.

The region at the lower end of the trunk, in the interval between the two thighs, where the

external genitalia are located is called perineum.

The pelvic outlet is a diamond shaped space and it presents boundaries49 :

o In front: lower border of symphysis pubis and arcuate pubic ligament.

o Behind: tip of the coccyx.

o Anterolaterally: ischiopubic rami and ischial tuberosities.

o Posterolaterally: Sacrotuberous ligament covered by the gluteal maximus.

Divisions: 50

A transverse line joining the anterior parts of the ischial tuberosities and passing

immediately anterior to the anus, divides the perineum into 2 trianglar areas, a posterior anal

region or triangle

An anterior urogenital region or triangle

Anal triangle:

o It has got no obstetrics significance.

o It contains the terminal part of the anal canal with sphincter ani externus, anococcygeal

body, ischiorectal fossa, blood vessels, nerves and lymphatics.

Urogenital triangle: 51

It is the anterior part of the pelvic outlet. The urogenital is closed by the following structures

i.e.from below upwards {superficial to deep}

a. Skin

b. Fatty layer of superficial fascia.

Chapter 3.4 Anatomy


c. Membranous layer of superficial fascia or fascia of colles.

d. Contents of the superficial perineal pouch.

e. Perineal membrane {inferior fascia of urogenital diaphragm}

f. Contents of the deep perineal pouch.

g. Superior fascia of urogenital diaphragm.

The superficial perineal pouch is formed by the deep layer of the superficial perineal fascia and

inferior layer of the urogenital diaphragm. The contents are superficial transverse perinea,

bulbospinongiosus covering the crura of clitoris and the Bartholin’s gland.

The deep perineal pouch is formed by the inferior and superior layer of the urogenital

diaphragm. Between the layers, there is a potential space of about 1.25cm. The contents are deep

transverse perinea and sphincter urethrae membranaceae. Both the pouches contain vessels and

nerves.

Perineal body:52 The perineal body, or the central point of the perineum, is a fibromuscular

node situated in the median plane, about 1.25cm infront of the anal margin and close to the bulb

of the vestibule.

The pyramidal shaped tissue where the pelvic floor and the perineal muscles and fascia

meet in between the vagina and the anal canal is called the obstetrical perineum.

Base is covered by the perineal skin and the apex is pointed and is continuous with

rectovaginal septum.

Nerve supply: Perineal branch of pudendal nerve.

Chapter 3.4 Anatomy


Actions of the urogenital diaphragm:

I. Supports the bladder.

II. Constricts the vagina.

III. Fixes the perineal body.

IV. Sphincter urethra exerts voluntary control of micturation and expels the last drops of

urine after the bladder stops contraction

Pudendal nerve

• It is the nerve of the perineum and of the external genitalia and is accompanied by

internal pudendal vessels.

• It arises from sacral plexuses in the pelvis and is derived from spinal nerves S2, 3, 4.

Branches: 53

• Inferior rectal nerve.

• Perineal nerve.

Applied anatomy:

The pudendal nerve supplies sensory branches to the lower one inch of the vagina, through the

inferior rectal and posterior labial branches.

In some conditions55, pudendal nerve block given. A 20ml syringe, one 15cm 17-20 gauze spinal

needle is placed on the tip of the ischial spine of one side and pierces in the vaginal wall on the

apex of ischial spine and pushes little to pierce the sacrospinous ligaments just above the ischial

spine tip, after aspirating blood, solution is injected.

Chapter 3.5 Disease review


PERINEAL TEAR

Due to extension of episiotomy, posteriory it involves the anal sphincter from back &

obliquely upwards into the lateral vaginal wall.

Condition favoring laceration include54 –

o Delivery of a large fetus.

o Malpresentations / Malpositions especially if instrumental rotation is performed.

o Delivery through narrow pubic arch.

Three degrees of perineal tear: 55

In the first degree, there is a laceration of skin & an exposure of superficial muscle

tissue.

In the second degree, there is tearing of the muscle of the pelvic floor.

In the third degree, anal sphincter & anal wall are disrupted.

Central tear involves lower end of the posterior vaginal wall and extends into peritoneum

or even rectum.



First & second degree tears56:-

Spontaneous tears originate near the midline of the perineum, but when they are traced upwards

they are invariably found to extend into one / other posteriolateral vaginal sulcus.

Sometimes the upper limit of the tear is felt better – helpful to catch the upper edge of the

vaginal tear.

If a double tear is found, care must be taken to unite the lateral vaginal walls to the loose

posterior tongue.

Tears of the anterior vaginal wall often involve the tissues close to the urethral meatus.

Later, pt. is unable to void urine because of muscle spasm consequent on the bruising

around the urethra & bladder neck.

Third degree tears:-

A tear has extended into the anal sphincter or canal.

Any fecal contamination is cleared away & area drenched with an aqueous solution of

antiseptic.

The muscle wall of the rectum & anal canal is closed by interrupted or continuous catgut

sutures (No.0) placed so that the suture avoids the bowel mucosa.

Disadvantage – appearance of small rectovaginal fistula at the upper end of the wound.

Repair of perineal tear57:

First degree:

Sometime doesn’t require suturing or can use one or two interrupted suture.



Second degree:

The vaginal mucosa is to be sutured first. The first suture is placed at or just above the

apex of the tear. Thereafter, the vaginal walls are opposed by interrupted sutures with chromic

catgut no. ‘O’ using curved body needle from above downwards till the fourchette is reached.

The sutures should include the deeper tissues to obliterate the dead space.

A continuous suturing may cause shortening of the posterior vaginal wall.

Complete perineal tear58:

The rectal and anal mucosa is sutured from above downwards by interrupted sutures.

Muscle walls including the pararectal fascia are then sutured by interrupted sutures. The torn

ends of the sphincter ani externus are sutured with figure of eight stitch by another interrupted

suture.

Perineal skin by interrupted suture



Episiotomy

Definition:

It is an incision on the perineum & the posterior vaginal wall during the second stage of

labour is called episiotomy.

It should be performed just before the crowning of head in second stage of labour.

Incidence66:

In UK and US it is commonly performed in primigravida for the spontaneous delivery. In

1983, Thacker and Banta reported that about 2/3rd of all vaginal deliveries in US are associated

with performance of episiotomy.

In 1987, Reynold and yudkin reported 28% decrease in the frequency of episiotomy over

a period of 4yrs. In the review of 20,000 women who underwent vaginal delivery, Owen and

Hanth reported that approximately 2/3rd of the primigravidas and 1/3rd of the multiparous had

episiotomies.

Objective67:

• To enlarge the vaginal introitus so as to facilitate easy & safe delivery of the fetus –

spontaneous or manipulative.

• To minimize over stretching & rupture of the perineal muscles & fascia;

• To reduce the stress & strain on the fetal head.

Indications59:

• In elastic or rigid perineum.

• Anticipating perineal tear – big baby, face to pubis delivery, breech delivery, shoulder

dystocia.

• Operative delivery: forceps delivery, ventouse delivery.

• Previous perineal surgery: pelvic floor repair, perineal reconstructive surgery.



Types60:-

Mid line: incision through the fourchette & perineal body.

Advantage: no large blood vessels are encountered & repair is very simple.

Disadvantage: extension of incision includes the anal sphincter or canal itself.

Lateral incision: may cause bleeding or the bartholian gland / duct may be injured &

considerable difficulty may be encountered in securing an accurate realignment of the

divided structures.

Posterolateral incision: starting at the midpoint of the fourchette or posterior commissure.

It has the advantage to the damage to the sphincter.

J shaped incision: in which after incising the perineum in the midline until a point is

reached 2-3 cm from the anterior margin of the anus.

Table no.2

Median Mediolateral Merits : -the muscles are not cut.

-blood loss is least.

-repair is easy.

-postoperative comfort is

maximum.

-healing is superior.

-Wound disruption is rare.

-Dypareunia is rare.

-relative safety from rectal

involvement from extension.

-if necessary, the incision can

be extended.



Demerits : -Extension, if occurs

involves rectum.

-Not suitable in

manipulative delivery or in

abnormal presentation or

position.

-Apposition of the tissues is

not so good.

-Blood loss is little more.

-Relative increased incidence

of wound disruption.

-Dyspareunia is more.

Advantages:

Maternal – Reduction in the duration of second stage.

Reduction of trauma to the pelvic floor muscles.

Fetal – it minimizes intracranial injuries.

The structures involved during mediolateral episiotomy are,

Posterior vaginal wall

Superficial and deep transverse perineal muscle, bulbospongiosus and part of levator ani.

Fascia covering those muscles.

Transverse perineal branches of pudendal vessels and nerves.

Subcutaneous tissue and skin.

Timing of the repair of episiotomy62:

The most common practice is to defer episiotomy repair until the placenta has been

delivered.

Early delivery of the placenta reduces blood loss from the implantation site because it

prevents the development of extensive retroplacement bleeding.

Advantage is that episiotomy repair is not interrupted or disrupted by delivery of

placenta, especially if manual removal must be performed.



Technique:

The suture material commonly used is 3-0 catgut.

Continuous catgut sutures for the vagina followed by two, three or exceptionally four

interrupted absorbable sutures for the deeper tissues & interrupted sutures for the skin &

muscle.

The apex of the vaginal incision is identified and the posterior vaginal wall repaired from

the apex to downwards.

A continuous suture offered for better haemostasis, the suture material used either

polyglycolic acid or chromic catgut 3-0.

The thread should not pulled too tightly as edema will develop during the first 24-48hrs.

One has to identify any vaginal lacerations, later it should be repaired. The deeper

interrupted sutures are then inserted to repair the perineal muscles. The skin is opposed

by interrupted sutures either with chromic catgut or nylon or silkworm gut using a cutting

needle

Complication61:

Immediate:

1. Extension of the incision: involves rectum, mainly in median episiotomy or occipito

posterior.

2. Vulval haematoma.

3. Infection.

4. Wound dehiscence: infection is the primary cause of wound disruption.

5. Injury to anal sphincter.

6. Rectovaginal fistula.



Remote:

• Dyspareunia due to narrow introitus.

• Chance of perineal lacerations.

• Scar endometriosis.

Vaginal lacerations 68

It involves middle or upper third of the vagina but not associated with lacerations of the

perineum or cervix.

These are common during forceps delivery or vaccum, sometime even with spontaneous

delivery.

These lacerations frequently extend deep into the underlying tissues and give rise to

haemorrhage, which is controlled by appropriate suturing.

The tears are repaired by interrupted or continuous sutures using chromic catgut no. ‘0’.



Cervical tear

• The cervix is lacerated in over half of vaginal deliveries.

• Most of these are less than 0.5cm.

• Deep cervical tears may be extended to the upper third of vagina.

• In rare instances, the cervix may be entirely or partially avulsed from the vagina, with

colporrhexis in the anterior, posterior or lateral fornices.

• Rarely, cervical tears may extend to involve the lower uterine segment & uterine artery &

its major branches & even through the peritoneum.

• Cervical lacerations upto 2 cm must be regraded as inevitable in childbirth. Such tears

heal rapidly.

• In healing, they cause a significant change in round shape of the external os before

cervical effacement & dilatation to that of appreciable lateral elongation after delivery.

Diagnosis69:-

A deep cervical tear should always suspected in cases of profuse haemorrhage during & after

third stage labour, if the uterus is firmly contracted.

• Extent of the injury can be fully appreciated only after adequate exposure & visual

inspection of cervix.

Treatment:

• Deep cervical tears require surgical repair when the laceration is limited to the cervix or

extends into the vaginal fornix, results are obtained by suturing the cervix. Either

interrupted / running absorable sutures are suitable.



Wound healing

• Healing by primary intension occurs in clean incised wounds such as surgical incision.

• It produces a clean, neat, thin scar.

• Healing by secondary intension refers to a wound which is infected, discharging pus or

wound with skin loss.

Process of wound healing63:

1. Inflammation :-

• Immediately after disruption of tissue integrity either by accidental trauma or by

surgeon’s knife, inflammation starts. The blood vessels undergo transient

vasoconstriction followed by vasodilatation.

• Histamine is considered to be the primary mediator of inflammatory vascular response.

• The wound healing may proceed normally in the absence of granulocytes and

lymphocytes, but monocytes must be present to create normal fibroblasts production.

• Depression of monocytes will delay wound healing.

2. Epithelization:-

• Occurs mainly from the edges of the wound by a process of cell migration and cell

multiplication.

• Thus, within 48hrs entire wound is re-epithelized when there is wound with skin loss,

skin appendages help in epithelization . Slowly surface cell keratinized.

3. Wound contraction:- • It starts after 4 days & is usually completed by 14 days.

• It is brought about by specialized fibroblasts, because of their contractile elements, they

are called myofibroblasts.

• Wound contraction occurs when there is loose skin as in back, gluteal region etc.

• Corticosteroids, chemotherapy delay wound contraction.



3. Connective tissue formation:-

• Formation of granulation tissue is the most important and fundamental step in wound

healing.

• Injury results in the release of mediators of inflammation mainly histamine from

platelets, mast cells and granulocytes results in increased capillary permeability.

• Later kinins and prostaglandin act and they play a chemotactic role for white cells and

fibroblasts.

• In the first 48hrs, polymorphonuclear leukocytes dominate , helps in removal of dead

and necrotic tissue

• Between 3rd and 5th day, polymorphonuclear leukocytes diminish in number but

monocytes increase.

• By 5th or 6th day, fibroblast appear , proliferate and give rise to a protocollagen

hydroxylase.

• Fibroplasias along with capillary budding give rise to granulation tissue.

• Secretion of ground substance, mucopolysaccharides by fibroblasts

proteoglycans help in binding collagen fibers.

• Thus, wound is FIBER-GEL-FLUID SYSTEM.

5. Scar formation:

Following changes takes place,

Fibroplasias and laying of collagen is increased.

Vasclarity becomes less.

Epithelialisation continues.

Ingrowth of lymphatics and nerve fibers takes place.

Remodelling of collagen takes place with cicatrisation , resulting in a scar.



Factors influencing wound healing64:

1. General:

Age

Nutrition - protein deficiency, vitamin c and vitamin A deficiency.

Hormones – corticosteroid

Medical disorder – Anaemia , Jaundice, Diabetes, Blood dyscrasis.

2. Local:

Position of wound, faulty technique of wound closure.

Poor blood supply, Impairment of lymphatic drainage.

Tension.

Movement.

Exposure to ionizing radiation.

Foreign bodies tissue reaction and inflammation, necrosis.

Chapter 3.3 Seevana karma


xÉÏuÉlÉ MüqÉï

Derivation:

From YsÉÏ mÉëirÉrÉ - xÉÏurÉÑ iÉliÉÑ xÉliÉÉlÉå & srÉÑOèû mÉëirÉrÉ+Ì¹uÉÑ 26

Amara kosa, mentioned as xÉÔcÉÏÌ¢ürÉÉrÉÉ: |27

According to Monier Williams28,

Sewing

Stitching

Suture

Surgical suture used to hold body tissue together after injury or surgery. Sutures

must be strong enough to hold tissue securely but flexible enough to be knotted.

xÉÏuÉlÉ rÉÉãarÉÌuÉÍkÉ 29:

The disciple, even after complete study of the entire scripture, they are subjected to

practical work. One even having acquired great learning is unfit for the profession if he has not

done the practical work. Suturing should be practiced in two ends of fine and thick cloth and

soft skin.Whereas Dalhana mentioned mrudu charma as mamsa pesi and mamsa varti.



vÉx§É MüqÉï of xÉÏuÉlÉ 30:

• xÉÔcrÉ: xÉÏuÉlÉã |

Needles (Suchi) are used for suturing; it may be different in length.

It should be 2 angula in length.

Some opines that when it is more in number it is considered as “suchya”.

Astanga Hridaya, mentioned about different measures of needles in different varieties and it should be uÉ×¨ÉÉ aÉÔRûSÛRûÉ, 31

oÉWÒû qÉÉÇxÉ - §rÉXçaÉÑsÉ

AsmÉqÉÉÇxÉ AÎxjÉxÉÎlkÉ - ²rÉÉXçaÉÑsÉ

Indications: 32, 33, 34

• xÉÏurÉÇ MÑü¤rÉÑSUÉ±Ç iÉÑ aÉqpÉÏUÇ rÉÌ²mÉÉÌOûiÉqÉç || (cÉ.ÍcÉ.25/60)

• AmÉÉMüÉãmÉSìÓiÉÉ rÉã cÉ qÉÉÇxÉxjÉÉ ÌuÉuÉ×iÉÉ¶É rÉã

rÉjÉÉå£Çü xÉÏuÉlÉÇ iÉåwÉÑ MüÉrÉïÇ xÉlkÉÉlÉqÉåuÉ cÉ || (xÉÑ.ÍcÉ.1/45)

It is indicated in wounds which are suppurated, incised and well scraped lesions, diseases

caused by medas, those situated in moving joints & muscles, in opening of abdomen.

The newly formed traumatic wounds which are not wide should be sutured immediately,

and also which are formed by scraping fatty tumours, pinna of the ears which are thin, ulcers

located on the head, nose, Lips, cheeks, buttocks etc; which are located in fleshy and immovable

parts are sutured.



Contraindication: 35

• lÉ ¤ÉÉUÉÎalÉÌuÉwÉæeÉÑï¹É lÉ cÉ qÉÉÂiÉuÉÉÌWûlÉÈ lÉÉliÉsÉÉãïÌWûiÉvÉsrÉÉ¶É iÉãwÉÑ xÉqrÉÎauÉvÉÉãkÉlÉqÉç || xÉÑ.xÉÔ.25/17

Suturing should not be done in wounds affected with kshara, Agni / visha, if wound is

present in groin, axilla etc., which is having less muscular support and movable, ulcers which

is filled by vayu, where foreign body is located. In these cases, the wound should be cleaned

properly.

xÉÏuÉlÉ SìurÉ & ÌuÉÍkÉ:-36

Suturing should be done after removing pieces of bones, blood clots, grass, hairs etc., by

keeping the torn and hanging pieces of muscles in their proper places, placing joints and bones in

their places and after stopping bleeding, it should be sutured slowly with fine fiber of tendons,

threads or inner fibers of bark trees (AvÉqÉliÉMü, zvÉhÉeÉ, ¤ÉÉæqÉ, xÉÔ§É, xlÉÉrÉÑ, qÉÑuÉÉï, aÉÑQÕûcÉÏ), for

continuous or interrupted suture.

The needle for suturing in less musculature part and in joint, should be circular and of 2

fingers in length, for fleshy part, 3 fingers long and should be 3 edged ,while for vital spot,

scrotum and abdomen it should be curved like bow, it should be rounded like tip of the pedicle of

the jati flower.

xÉÏuÉlÉ mÉëMüÉU 37, 38

Vellitaka

Gophanika

Tunnasevanee

Rujugranthi



uÉåÎssÉiÉMü:-

It is uÉ¢Ç (Encircling of a creeper to a tree / pole).

This is known as Glover’s continuous suture. Such sutures are placed for clean aseptic wounds.

The continuous suture is generally used for anastomosis of the guts, deep fascia,

external oblique aponeurosis etc. the advantage is that the suture can be quickly applied

and also haemostatic.

The disadvantage is that, if hematoma or infections occurs, one cannot remove a

part of the suture and drain the wound. In this process, the whole suture will be damaged

& the wound will gape. So, this is not used in the presence of infection.

aÉÉåTüÍhÉMü :-

It is aÉÉåTühÉÉMüÉUÉqÉç |

Gophana is an appliance used by farmers to ward off the birds etc. which fall upon the

paddy field.

The farmer keeps a stone piece in that, holds the long thread of that, rings around 3 or 4

times & then throws it on the birds. The threads & appliance will be in his hand & the stone

hits the target.

In modern terms it is called button hole or blanket suture.

It is a type of continuous suture, where the needle is passed through the loop of each

stitch.



iÉÑ³ÉxÉåuÉlÉÏ:

This is just similar to the stitches of a trouser bottom. The thread is not seen externally.

This means needle does not pass through & through. It is known as cosmetic / subcuticular

suture. The running subcuticular suture is a buried form of the running horizontal mattress

suture. It is placed by taking horizontal bites through the papillary dermis on alternative sides

of the wound.

The running subcuticular suture is begin by placing the needle through one wound edge

and enters into the defect. The opposite edge is held firmly with a skin hook as the needle is

passed in a horizontal pattern through the mid dermis. It exits with a 1/2 cm. pass and then is

brought in approximation to the opposite wound side and enters the mid dermis. This is repeated

on alternate sides of the wound as the suture is advanced down the wound edge. The suture can

be removed promptly by pulling out along the long axis of the scar line.

The subcuticular suture is used primarily to enhance the cosmetic results with defects in

which tension has been fully reduced and the skin edges are of relatively equal thickness.

Uses:

The running subcuticular suture is valuable in areas in which the tension is minimal, the

dead space has been eliminated, and the best possible cosmetic result is desired.

The suture does not provide significant wound strength, although it does precisely

approximate the wound edges. Therefore, the running subcuticular suture is best reserved for

wounds in which the tension has been eliminated with deep sutures, and the wound edges are of

approximately equal thicknesses.



HeÉÑaÉëÎljÉ:-

Straight knot & / is known as interrupted suture. In this individual sutures are separated

from one another. This may be single / double interrupted suture

The knots are placed on the sides of the wound to avoid wound depression.

This suture is placed by inserting the needle perpendicular to the epidermis, traversing the

epidermis and the full thickness of the dermis, and existing perpendicular to the epidermis on the

opposite side of the wound. The 2 sides of the stitch should be symmetrically placed in terms of

depth and width.

Grasping the end of the suture with a pair of forceps and the opposite side with a needle

holder, the surgeon can test the closure tension along the skin edge & tie the knot.

Uses:

Compared with running sutures, interrupted sutures are easy to place, have greater tensile

strength, and have less potential for causing wound edema and impaired cutaneous circulation.

Disadvantages of interrupted sutures include the length of time required for their placement and

the greater risk of crosshatched marks (i.e, train tracks) across the suture line.

More time needed to tie individual knots

• Poor suture economy

• Increased amount of foreign material in the wound.



Precaution: - 39

Suture should not be put neither too far nor too near as the former would cause pain while

the latter pulls out the margin of the ulcer.

mÉ¶ÉÉiÉç MüqÉï :- 40,41

After suturing the wound, it should be covered with linen or cotton cloth and powder of

priyangu, anjana, madhuyasti & lodhra or that of sallaki fruit or ash of linen should be sprinkled

all round. Or Swab which is soaked in a mixture of honey, melted ghee, anjana, ash of ksauma,

phalini, and fruit of sallaki, rodhra and madhuka should be used.

Chapter 4.2 Observations


OBSERVATION

01. Distribution of patients according to age:

Table no.3

Age (In years)

No.

%

20‐25

19

38

26‐30

26

52

31‐35

4

8

36‐40

1

2

Graph no.1

0

10

20

30

40

50

60

no %

Age disribution

20‐25

26‐30

31‐35

36‐40

Among 50 patients, 52% in 26-20 yrs, 38% of patients were in the age group of 20-25

yrs, 8% in 31-35 yrs and 2% in 36-40yrs.



02. Distribution of patients according to religion:

Table no.4

Religion

No.

%

Hindu

35

70

Muslim

14

28

Christian

1

2

Graph no.2

0

10

20

30

40

50

60

70

80

no %

Religion distribution

hindu

muslim

christian

Among 50 patients, 70% patients belong to Hindu religion, 28% to Muslim and 2% to Christian.



03. Distribution of patients according to socioeconomic status:

Table no.5

S-E status

No.

%

Upper

10

20

Middle

35

70

Lower

5

10

Graph no.3

0

10

20

30

40

50

60

70

80

no %

S-E status distribution

upper

middle

lower

Among 50 patients, 70% belong to middle class, 20% patients belong to upper middle class, and

10% patients belong to lower middle class.



04. Distribution of patients according to occupation:

Table no.6

Occupation

No.

%

House wife

43 86

Teacher

4

8

Tailor

3

6

Graph no.4

0

10

20

30

40

50

60

70

80

90

100

no %

occupation distribution

H.W

teacher

tailor

Among 50 patients, 86% patients were Housewife, 8% were teacher and 6% were tailor.



05. Distribution of Patients according to religion

Table no.7

Region No. %

Urban 13 26

Rural 37 74

Graph no .5

Among 50 patients, 74% from rural area, 26% from urban area.



06. Distribution of patients according to Education:

Table no.8

Education

No. %

Primary

20

40

High school

7

14

Graduate

23

46

Graph 6

0

5

10

15

20

25

30

35

40

45

50

no %

Education distribution

primary

high sch

graduate

Among 50 patients, 46% were graduated, 40% were from primary school, and 14% were from high school.



07. Distribution of patients according to parity:

Table no.9

Parity

No.

%

Primigravida

31 62

Multipara

19 38

Graph 7

0

10

20

30

40

50

60

70

no. %

Parity distribution

primi

mutli

Among 50 patients, 62% patients were primigravida and 38% patients were multipara.



08. Distribution of patients according to diet history:

Table no.10

Diet

No.

%

Vegetarian

18

36

Mixed

32

64

Graph no.8

0

10

20

30

40

50

60

70

no %

Diet distribution

veg

mixed

Among 50 patients, 64% were having mixed diet and 36% were vegetarian.



09. Distribution of patients according to Prakruthi:

Table no.11

Prakruthi

No.

%

Vatapitta

17

34

Vatakapha

17

34

Pittakapha

16

32

Graph no.9

0

5

10

15

20

25

30

35

40

no %

Prakruthi distribution

vatapitta

vatakapha

pittakapha

Among 50 patients, 34% patients are of vatapitta and vatakapha prakruthi, 32% are of

pitta kapha prakruthi.



10. Distribution of patients according to Saara:

Table no.12

Saara

No.

%

Pravara

2

4

Madhyama

45

90

Avara

3

6

Graph no.10

:

0102030405060708090100

no %

Saara distribution

pravara

madhyam

avara

Among 50 patients, 90% belongs to madhyama saara, 6% belongs to avara saara and 4% belongs to pravara.



11. Distribution of patient according to sattva:

Table no.12

Sattva

No.

%

Pravara

2

4

Madhyama

47

94

Avara

1

2

Graph no.10

0

10

20

30

40

50

60

70

80

90

100

no %

Sattva distribution

pravara

madhyam

avara

Among 50 patients, 98% are of madhyama sattva and 2% are of avara sattva .



12. Distribution of patients according to samhanana:

Table no.14

Samhanana

No.

%

Pravara

6

12

Madhyama

39

78

Avara

5

10

Graph no.12

0

10

20

30

40

50

60

70

80

90

no %

samhanana distribution

pravara

madhyam

avara

Among 50 patients, 78% were having madhyama samhanana, 12% are pravara and 10%

are in avara.



13. Distribution of patients according to Satmya:

Table no.15

Satmya

No.

%

Pravara

12

24

madhyama

30

60

Avara

8

16

Graph no.13

0102030405060708090

no. %

Satmya distribution

pravara

madhyam

avara

Among 50 patients, 60% patients belongs to madhyama , 24% belongs to pravara and 16% belongs to avara.



14. Distribution of patients according to Aharashakthi:

Table no.16

Aharashakthi

No.

%

Pravara

1

2%

Madhyama

45

90%

Avara

4

8

Graph no14.

Among 50 patients, 90% patients have madhyama ahara shakthi , 8% are having avara

and 2% having pravara sattva



15. Distribution of patients according to vyayama shakthi:

Table no.17

Vyayama shakthi

No.

%

Pravara

5

10

Madhyama

43

86

Avara

2

8

.

Graph no.15

Among 50 patients, 86% patients are having madhyama , 10% are having pravara and 8%

are having avara vyayama shakthi



16. Distribution of pt in suturing pattern of skin:

Table no.18

Sutures

No.

%

subcuticular

11

22

Mattress

39

78

Graph no.16

Among 50 patients, 78% of patients undergone mattress type of sutute & 22% are having

subcuticular suture.



17. Distribution of patients in suturing pattern of muscle layer:

Table no.19

Suture

No

%

Continuous

13

26

interrupted

37

74

Graph no.17

Among 50 patients, 74% of patients undergone mattress type of suture & 26% are of

continuous suture.



18. Incidence of patients in suturing pattern of mucous layer

Table no.20

Mucous layer

No

%

Continuous

50

100

Other types

0

0

Graph no.18

0

20

40

60

80

100

120

no %

Suturing pattern in mucous layer

conti.

other

Among 50 patients, 100% patient’s mucous layer is sutured by continuous suture.



19. Incidence of Seevana karma in different lacerations:

Table no.21

Seevana karma

No.

%

Episiotomy

35

70

Perineal tear

6

12

Cervical tear

7

14

Vaginal laceration

2

4

Episiotomy & perineal tear

4

8

Graph no.18

Among 50 patients, 70% patients given episiotomy and suturing done, 12% perineal tear

suturing done, 7% of cervical tear sutured and 2% vaginal tear sutured.



20. Incidence of complication in different types of suturing:

Table no.22

Complication (wound gaping with slough)

No.

%

Present

5

10

Absent

45

90

Graph no.20

Among 50 patients, 90% patients does not have any complications but in 10% patients gaping of

wound along with presence of slough formation noticed.



21. Distribution of patient in haematoma formation after suturing:

Table no. 23

Haemotoma formation

No.

%

Present

3

6

Absence

47

94

Graph No. 21

Among 50 patients, in 84% patients suture healthy, but in 6% patient haemotoma noticed.



22. Incidence of pain according to days:

Day 1: Table no.24

Pain

No. %

Severe

33 66

Moderate

17 34

Mild

0 0

No pain

0 0

Among 50 patients, 66% patients are having severe pain on first day and 34% patients are

having moderate pain.

Day 2: Table no.25

Pain

No.

%

Severe

5

10

Moderate

27

54

Mild

18

36

No

0

0

Among 50 patients, 54% patients are having moderate pain, 36% having mild pain and

10% having severe pain on second day.



Day 3: Table no.26

Pain

No. %

Severe

1

2

Moderate

4

8

Mild

36

72

No

9

18

Among 50 patients, 72% are having mild pain, 18% having absence of pain, 8% having

moderate pain and 2% having severe pain.

Day 4: Table no.27

pain

No.

%

Severe

0

0

Moderate

2

2

Mild

25

50

No

23

46

Among 50 patients, 50% having mild pain, 44% having absence of pain and 2% having

moderate pain.



Day 5: Table no.28

Pain

No.

%

Severe

0

0

Moderate

2

4

Mild

8

16

No

40

80

Among 50 patients, 80% having absence of pain on 5th day, 16% having mild

pain, and 4% having moderate pain.

Graph no.22



24. Incidence of Resuturing of wound:

Table no.29

Resuturing of wound

No.

%

Resuturing

1

2

Not done

49

98

Graph no.23

Among 50 patients, in one patient i.e.2% resuturing of wound done, remaining 98%

sutures are healthy.



25. Distribution of patients according to suture Absorption in days:

Table no.29 - In this 11 patients are having Subcuticular sutures, so sutures does not fall down.

Days

No.

%

4th

4

8

5th

10

20

6th – 15th

25

50

Graph no.24

Among 50 patients, 50% patients sutures fallen down between 6th – 15th day, 20%

patients sutures fell down on 5th day of delivery, 8% patients on 4th day and remaining 22%

patients having subcuticular suture.



26. Distribution of patients according to wound healing:

On 15th day: Table no.31

Suture

No.

%

Subcuticular

11

22

Mattress

10

20

Graph no.25

Among 50 patients, 22% patient have subcuticular suture this wound was completely

healed on 15th day, 78% patient have mattress suture, in this 20% patient wound was completely

healed on 15th day. Remaining patient wound was healing.



On 30th day: Table no.32

Suture

No.

%

Subcuticular

11

22

Mattress

39

78

Graph no.26

Among 50 patients, 78% patients on 30th day, complete healing of wound and in 22%

after complete healing, thin scar noticed.

Chapter 4.1 Clinical study


CLINICAL STUDY

Objective of the study:

• Conceptual study on utility of Ashtavidha shastra karma in prasoothi tantra & stree roga.

• Conceptual study of seevana karma with its classification & method of its application.

• Analysis of different types of seevana karma in repairing of episiotomy, lacerations of

genital tract.

Materials and methods:

Source of data:

Minimum 50 parturating patients of labour subjected to episiotomy, suffered with lacerations in

genital tract will be selected for the study from S.D.M. Ayurveda hospital kuthpady, Udupi.

Method of data collection:

It is a descriptive study on different types of seevana karma, where the method of

selecting data is by participant observation method.

A minimum of 50 patients, diagnosed under inclusive criteria will be taken. The seevana

vidhi is observed with results & the utility of seevana vidhi is evaluated.

A detailed proforma is prepared considering all points pertaining to history, course of

labour, obstetric examination etc.

Inclusion criteria:

• Patients with age group of 21 to 40 years.

• Patients of both primi & multi gravida.

• Patients subjected to episiotomy.

• Patients of all types of lacerations i.e. cervical, perineal.

Chapter 4.1 Clinical study


Exclusion criteria:

• Past history of perineal operations.

• Patients suffering from systemic disorders, hypertension, thyroid dysfunction, infections

& respiratory disorders.

Intervention:

After the diagnosis of particular conditions, the seevana karma will be observed. Later 3

groups are made based on the conditions such as perineal, cervical lacerations & episiotomy.

• Group A suturing techniques & mode of action observed in episiotomy.

• Group B suturing techniques & mode of action observed in perineal lacerations.

• Group C suturing techniques & mode of action observed in cervical tears.

Assessment criteria:

• To know the efficacy of combination of seevana karma & its different techniques in

repairing of different types of lacerations of genital tract.

• Effectively & side effects of suturing methods in episiotomy, lacerations of genital tract

will be analysed.

Final assessment:

In cervical tear shape of cervix, everted edges & any discharge due to cervical injury are

observed.

In episiotomy , perineal laceration healing of perineal wound, tone of the perineal muscle,

any tenderness during movements , difficulty in sitting down posture are assessed

Chapter 5 Discussion


DISCUSSION

Astavidha shastra karma is the fundamental procedure for the development of surgery

which includes chedana, bhedana, seevana etc.

Episiotomy is a small incision given on the stretched perineum at the time of crowning of

head. It is commonly practiced nowadays. It was first introduced somewhere over 200years ago,

but came to be favoured around 1918. The main aim of practicing episiotomy by modern

obstetricians was to protect the fetal head and to preserve the integrity of the pelvic floor, to

prevent injury to the fetal head & also given to prevent 3rd and 4th degree tear and lacerations.

In Mudhagarbha chikitsa, while explaining the management for difficulties during

extraction of fetus, utkartana karma is mentioned as one of the procedure, this can be considered

as episiotomy.

Seevana karma is mentioned as a procedure in the management of Vrana. For suturing,

different varieties of needles are mentioned with its different length. The object of suturing is to

approximate the cut edges so they will heal rapidly, leaving a minimal scar. Edges to be opposed

and cut given in a clean line and perpendicular to the skin surface. The cut edges are brought

together neatly, without stretching.

In classics, 4 types of seevana karma mentioned i.e.

a. Vellitaka or Glover’s continuous suture are used for suturing mucosal layer of

Episiotomy wound, because it is a haemostatic. Disadvantage of this is, if there is

any haemotoma, infection present, cannot remove one suture instead of this whole

suture has to remove.

b. Gophanika or blanket suture is also one type of continuous suture.

c. Tunnasevani or cosmetic suture or subcuticular suture, this type of suture does not

provide significant wound strength, risk of infection is low and perfect

haemostasis is not achieved.

d. Rujugranthi or interrupted suture, these are easy to place, have greater tensile

strength and less potential for causing wound edema and impaired cutaneous

circulation. Having less disadvantages.



Mattress suture is a type of interrupted suture, it is useful in eversion of wounds, reduces

the dead space and minimizes the stretching across the wound.

Suture material are divided into absorbable and non absorbable, absorbable suture

materials are catgut and polyglycolic acid. They cause less tissue reaction, having more tensile

strength & are absorbed slowly. Catgut is the oldest suture material & is made from the sub

mucosa of sheep intestine. Absorption mainly occurs in 2 ways i.e. by enzymatic reaction and by

hydrolysis. When the material starts absorbing, it loses its tensile strength. Absorbable synthetic

sutures are commonly used for subcuticular wound closure and for interrupted suture in skin it is

used.

Non absorbable sutures i.e. silk, nylon, they are easy to handle & one can tie easily.

Disadvantage is increased tissue reaction and sepsis, caused by the capillary action of materials

taking microorganisms into the tract. So these materials also lose tensile strength quickly with

time. Mersillin suture material cause less tissue reaction. And even nylon also causes less tissue

reaction. They free from the capillary effect of braided sutures and cause less suture track sepsis.

In our classics, asmanthaka, shanaja, ksuama, murva, guduchi, snayu are used as a suture

material. As paschat karma, wound should be covered with powder of priyangu, madhuyasti and

lodhra are mentioned.

Studies have shown that the IQ of children born after episiotomy is good compared to

that of children born without episiotomy. Without episiotomy prolonged stay of the head in

perineum leads to intracranial injuries, asphyxia and mother could be affected by 3rd or 4th degree

tear which is hard to repair compared with episiotomy.

The demerits of the episiotomy, if extension occurs, involves rectum, relative increased

incidence of wound disruption. And also one more factor responsible for wound healing, during

puerperal period, advised strict diet and complete rest. The rich vascularity to the region also

favours the wound healing.

The wound heals by 4-6 weeks, depending on the size of the incision and type of suture

material used to close the wound. The mechanism of wound healing depends on certain factors

i.e. vitamin, trace elements and protein deficiency may delay the wound healing or breaks down



the wound. Improper wound care may give rise to infection, wound dehiscence, so healing may

be delayed. Healing by the secondary and tertiary intension causes excessive fibrosis.

Discussion on observational study:

Age group: In this study, 52% belonging to 26-30yrs, 38% are of 20- 25yrs, 8% are of 31-35 yrs

& 2% are of 36-40 yrs. Healing was good in all patients, due to their young age and the wound is

afresh one.

Religion: In this study, 70% belongs to Hindu religion, 28% are of Muslim and 2 % are of

Christian. This reflects the geographical distribution of population in this area.

Socio economic status: In this study, 70% belong to middle class, 20% patients belong to upper

middle class, and 10% patients belong to lower middle class. The S.D.M. Hospital is a charity

hospital and most patients visiting to the hospital are of middle class.

Occupation: In this study, 86% patients were Housewife, 8% were teacher and 6% were tailor.

During post natal period, the patient is under rest, wound healed well irrespective of occupation.

Region: In this study, 74 % are from rural area and 26% are from urban area. The majority of

the patient came from rural area. As the hospital is situated in the urban area, it is surrounded by

several villages representing the rural areas. This could be the reason why patients were from

rural area.

Education: In this study, 46% were graduated, 40% were from primary school, and 14% were

from high school.

Parity: In this study, 62% patients were primigravida and 38% patients were multipara.

Clinically it was seen that healing was quicker in primis than in multis.

Diet: In this study, 64 % were having mixed diet and 36% were vegetarian. The area where

study was conducted is costal area. Most of the people are doing fish business & having the same

as their main food. This gives observation that most of patient has mixed type of dietary habit.



Pareekshya bhavas:

The present on Prakruthi, 34% patients are of vatapitta and vatakapha prakruthi, 32%

are of pitta kapha prakruthi.

The present study on Saara, 90% belongs to madhyama saara, 6% belongs to avara saara

and 4% belongs to pravara.

The present study on Sattva, 94% are of madhyama sattva, 4% are of pravara sattva and

2% are of avara sattva.

The present study on Samhanana, 78% were having madhyama samhanana, 12% are

pravara and 10% are in avara.

The present study is on Satmya, 60% patients belong to madhyama, 24% belongs to

pravara and 16% belongs to avara.

The present study is on Ahara shakthi, 90% patients have madhyama ahara shakthi , 8%

are having avara and 2% having pravara sattva.

The present study on Vyayama shakthi, 86% patients are having madhyama , 10% are

having pravara and 8% are having avara vyayama shakthi.

Incidence of suturing pattern in skin:

In this study, 78% of patients undergone mattress type of suture & 22% are having

subcuticular suture. Mattress suture opted by many physician, it is easy to place and haemostasis,

whereas in subcuticular suture, haemostatasis occurs, still applied as cosmetic purpose.

Incidence of suturing pattern in muscle layer:

In this study, 74% of patient undergone interrupted type of suture & 26% of continuous

suture. One or two sutures removed in case of infection in interrupted suture, whereas in

continuous suture whole suture removed, later it leads to wound gaping.



Incidence of suturing pattern in mucosa:

In this study, 100% patient’s mucosal layer is sutured by continuous suture. As it is easy

to place and quickly applied and complete haemostasis achieved.

Incidence of seevana karma in lacerations:

In this study, 70% patient’s undergone episiotomy and suturing done, all cases were

primigravidas.

12% perineal tear noticed, these are multigravida, without episiotomy, baby delivered and

it was first degree perineal tear and sutured by simple suture.

7% cervical tear and 2% vaginal tear are sutured in cases of assisted deliveries by

instrumentation with the indication of fetal distress, interrupted sutures are applied in all cases.

Incidence of complication in suturing techniques:

In this study, 90% patients are free from complications but in 10% patients complications

observed i.e. gaping of wound noticed on 4th and 5th day may be due to different postures,

occurrence of cough and constipation, less vascularity or deficiency of enzymatic factor. Slough

formation on wound noticed due to improper hygiene.

Incidence of haemotoma formation: In this study, 94% patient’s sutures were healthy, but in 6% patient’s haemotoma

noticed. As all of these were instrumental deliveries. Haemotoma may be due to deep cervical

tear, injury to blood vessels.

Incidence of pain: In this study, 66% patients are having severe pain and 34% patients are having moderate

pain on first day

54% patients are having moderate pain, 36% having mild pain and 10% having severe

pain on second day.

72% patients are having mild pain, 18% having absence of pain, 8% having moderate

pain and 2% having severe pain on 3rd day.



50% patients are having mild pain, 44% having absence of pain and 2% having moderate

pain on 4th day.

80% patients are having absence of pain, 16% having mild pain, and 4% having moderate

pain on 5th day.

Compare to interrupted suture, in subcuticular suture pain is less, patient does not feel

discomfort for sitting

Incidence of Resuturing of wound:

In one multigravida patient resuturing was done as the wound spontaneously opened on

3rd day probably due to anaemia and increased elasticity on perineal muscle. Later suturing was

done. As it is rare case it does not represent usual statistical occurrence.

Incidence of suture absorption in days:

In this study, Catgut is used for suturing, which gets absorbed within 10days. As ten days

hospital stay is not agreeable, so patients were discharged by 5th day. In the period of their

hospital stay, those people undergone mattress suturing, 8% patients suture absorbed on 4th day ,

20% patients suture absorbed on 5th day, 50% patient’s suture absorbed between 6th – 15th day .

Incidence of wound healing:

In this study, 22% patient’s undergone subcuticular suture, on 15th day wound was

completely healed and on 30th day thin scar was noticed.

78% patient’s undergone mattress suture, in this 20% patient’s wound was completely

healed on 15th day. Remaining 58% patient’s suture was completely healed on 30th day.

Chapter 6 Summary & conclusion


SUMMARY AND CONCLUSION

The present dissertation study entitled “Clinical study on utility of different types of

seevana karma in episiotomy, lacerations of genital tract” is planned.

The whole study can be divided into,

• Conceptual study

• Clinical study

• Discussion

• Conclusion

1. Introduction: This chapter describes the need for the study and aim of under taking the

study.

2. Review of literature:-

2.1 Historical review: This chapter deals with the historical aspects of seevana karma.

2.2 Introduction of Astavidha Shastra karma: This chapter contains, different types of

shastra karma acc. to Acharyas, shastra payana vidhi, doshas of shastra, qualities of

shastra mentioned.

2.3 General description of Seevana karma: This chapter describes derivation of

seevana, yogya vidhi, shastra karma, indication, contraindication, types of seevana

along with its advantages and disadvantages, suturing material, procedure, pashcat

karma, precaution while suturing.

2.4 Anatomy of cervix, vagina, perineum.

2.5 Modern review: Degrees of perineal tear, repair of perineal tear, indication,

contraindication, merits, demerits, and types, procedure, timing of repair,

complication of episiotomy, vaginal tear, and cervical tear with its repair is

described in detail in this chapter.



3. Clinical study :

3.1 Materials and Methods: including selection of patients for study, plan of study and

criteria of assessment.

3.2 Observations: Here the incidence of occurrence of various criteria has been

observed corresponding observations have been drawn.

4. Discussion: It is based on the observations obtained after the completion of the study done

here.

5. Conclusion :

Benefits of seevana karma:

• The karya of seevana is Sandhana.

Here concluding remarks have been made and future scope of study on this topic is mentioned. Based on the present study it is summarized that, Seevana karma is the one of the

Astavidha Shastra karma, & it is one of the Vranashasti upakrama. Utkartana karma which is

mentioned in Mudhagarbha chikitsa describes about an incision. Episiotomy is performed to cut

short the 2nd stage of labour and to prevent perineal injuries. Suturing of the different layers of

episiotomy is done by different types of seevana karma and the wound is closed.

The wound was observed in everyday of hospital stay & result derived,

• In this study, 70% patient underwent episiotomy. For suturing mucosal layer Vellitaka

(continuous suture ) opted,

• For suturing muscle layer, 74% patient undergone Rujugranthi (interrupted suture) &

26% undergone Vellitaka (continuous suture),

• For suturing skin, 78% patients undergone Rujugranthi (mattress suture this is a type of

interrupted suture ) & 22% having Tunnasevani (subcuticular suture)

• Among 50 patients, 14% cervical tear & 4% vaginal tear sutured by Rujugranthi

(interrupted suture).

• In 12% first & 2nd degree perineal tear observed & sutured by Rujugranthi (interrupted

suture).



To conclude,

• Vellitaka is easy to place, quickly applicable and leads to complete haemostasis.

• Rujugranthi is proved good in cases of infection as only one or two sutures can be

removed to drain any collection. Even though it is opened the integrity of suturing in

other part ensured.

• Vellitaka inspite of all its good qualities proves hard in cases of infection as whole suture

is needed to be removed leading to wound gaping.

• Tunnasevani applied in layer of twak ensured intensity of pain is less, discomfort and left

with fine scar within 15days.

• Gophanika by its nature of intermittent interlocking gives all the comforts provided by

vellitaka and same time is secured because of its interlocking.

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74

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Varanasi, Pp824:461

72. Bailey & Love’s short practice of surgery, Revised by Charles V.mann, 22nd

edition,1996, Published by elbs.Pp1041:26

73. www.ayurmedicine.com

74. www.google.com





No. %

4th 4 8

5th 10 20

6th – 15th 25 50

Distribution according to suture absorption

0

10

20

30

40

50

60

4th 5th 6th – 15th

orption

6th – 15th

No.

%

80

PROFORMA

1. ATURA VIVARA –

1. ATURA NAMA : 2. VAYA : 3. NIVASA : 4. JATI : H,M,C. OTHERS. 5. VYAVASAYA: 6. SAMAJIKA STITHI: 7. VIDHYABYASA : 8. ANTAHA KRAMANKA : 9. BAHIHAN KRAMANKA : 10. SHAYYAGARA KRAMANKA : 11. PRAVESHA DINANKA : 12. NIRGAMANA DINANKA :

2. VEDANA SAMUCHRAYAM –

I. PRADHANA VEDANA –

II. ADHYATANA VYADHI VRITTANTA –

III. POORVA VYADHI VRITTANTA – H/O DM, HTN, HIV, VDRL, TB. ANY OTHER. PREVIOUS SURGICAL HISTORY .

IV. KULA VRITTANTA –

V. POORVA RAJO VRITTANTA –

RAJA KALA – DAYS / DAYS. PRAMANA – ATI MADHYAMA ALPA. ASSOCIATED COMPLAINTS IF ANY –

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6. PRAJANANA VRITTANTA

No. Year & date Pregnancy Method of delivery Baby

8. CONTRACEPTIVE HISTORY :

SAFE PERIOD – CONTRACEPTIVE PILLS, IUCD , ANY OTHER.

DURATION OF USAGE –

COMPLICATIONS IF ANY –

9. PERSONAL HISTORY :

DIET – VEGETARIAN, NON – VEGETERIAN, MIXED.

SLEEP – SOUND, DISTURBED.

BOWEL –

MICTURATION – FREQUENCY : DAY -

NIGHT -

ANY HABITS-

3. DASHA VIDHA PAREEKSHA –

a) PRAKRITI : V,P,K,VP,PK,VPK. b) VIKRITI: c) SARA: d) SAMHANA : e) SATMYA: f) SATVA: g) PRAMANA: h) VAYA: i) ABHYAVARANA SHAKTHI / JARANA SHAKTHI: j) VYAYAMA SHAKTHI:

82

4. GENERAL EXAMINATION :

BUILT & NOURISHMENT :

WEIGHT:

PALLOR:

ICTERUS:

OEDEMA:

LYMPHADENOPATHY:

CYANOSIS:

5. VITAL SIGNS –

B.P.

PULSE RATE

R.R.

TEMP.

H.R.

6. SYSTEMIC EXAMINATION :

RESPIRATORY SYSTEM-

CARDIOVASCULAR SYSTEM-

GASTROINTESTINAL SYSTEM-

ANY OTHER –

7.STHANIKA PAREEKSHA –

INSPECTION :- 1.PARTICULAR–

i. NUMBER – ii. SITUATION –

iii. SHAPE , SIZE & DEPTH – iv. FLOOR - DISCHARGE / COLOUR/ SMELL.

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v. GRANULATION TISSUE vi. EDGE & MARGIN

2. VISIBLE MOVEMENTS: PULSATION 3. SURROUNDING SKIN : COLOUR/ TEXTURE / SHAPE /VISIBLE VEINS. 4.NEIGHBOURING STRUCTURES .

PALPATION : 1 2 3 4 5 1.TENDERNESS –

2. BLEEDING & FRIBILITY. 3.EDGE. 4.BASE. 5.SURROUNDING AREA : FEEL FOR TEMPERATURE / SENSATION.

MOVEMENTS OF THE LEG. 8. INVESTIGATIONS: BLOOD EXAMINATION: Hb%, R.B.S., HBsAg, HIV. URINE EXAMINATION : ROUTINE, MICROSCOPIC. 9.OBSERVATION OF DELIVERY :

a) BISHOP’S SCORE:

DATE&TIME

SCORE

DILATATION(cm)

EFFACEMENT(%)

Cx

STATION

CONSISTENCY

Vital data :

AFTER2ndDELIVERY DAY 1 DAY2 DAY 3 DAY 4 DAY 5.

B.P.

PULSE.

R.R.

TEMP.

H.R.

84

TYPE OF SUTURE –

HEALING OF SUTURE : 1 2 3 4 5 15 30

DURATION OF 1stSTAGE

DURATION OF 2ND STAGE

DURATION OF 3RD STAGE

b) COMPLICATION DURING LABOUR

c) CONCLUSION :

SIGNATURE OF THE STUDENT SIGNATURE OF THE GUIDE:

SIGNATURE OF THE CO – GUIDE:

DIFFERENT TYPES OF SEEVANA KARMA

Figure no.3 Figure no.4

Figure no.5

Rujugranthi (Interrupted suture)

Vellitaka (continuous suture)

Tunnasevani (Subcuticular suture)

Episiotomy

Suturing of different layers of Episiotomy

Performing Episiotomy

Figure no.7

Figure no.6

SHASTRA KARMA OF SEEVANA KARMA

Figure no.1

Figure no.2

Documents

Lacerations seevana psr