“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,
S. D. M. C. A., Udupi
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.,
S. D. M. C. A., Udupi
CERTIFICATE BY THE GUIDE
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE
I hereby declare that this dissertation entitled “CLINICAL STUDY ON UTILITY OF
DIFFERENT TYPES OF SEEVANA KARMA IN EPISIOTOMY,
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
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
CO-GUIDE
Dr.SUCHETHA, M.D. (Ayu)
Lecturer,
S. D. M. C. A., Udupi
CERTIFICATE BY THE CO GUIDE
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
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
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
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
Incidence of wound healing on 30th
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.
Intensity of pain on day 3
59
27.
Intensity of pain on day 4
59
28.
Intensity of pain on day 5
60
29.
Incidence of Resuturing of wound
61
30.
Incidence of suture absorption
62
31.
Incidence of wound healing 15th day
63
32.
Incidence of wound healing on 30th
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
2 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
3 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
4 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.1 Historical review
5 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.1 Historical review
6 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.1 Historical review
7 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
8 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
9 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
17 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
18 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
19 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
20 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
21 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
22 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
23 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
24 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
25 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
Chapter 3.5 Disease review
26 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
27 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
28 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
29 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
30 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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’.
Chapter 3.5 Disease review
31 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
32 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
33 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.5 Disease review
34 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
10 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
xÉÏuÉlÉ MüqÉï
Derivation:
From YsÉÏ mÉëirÉrÉ - xÉÏurÉÑ iÉliÉÑ xÉliÉÉlÉå & srÉÑOèû mÉëirÉrÉ+̹uÉÑ 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.
Chapter 3.3 Seevana karma
11 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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 uÉרÉÉ aÉÔRûSÛRûÉ, 31
oÉWÒû qÉÉÇxÉ - §rÉXçaÉÑsÉ
AsmÉqÉÉÇxÉ AÎxjÉxÉÎlkÉ - ²rÉÉXçaÉÑsÉ
Indications: 32, 33, 34
• xÉÏurÉÇ MÑü¤rÉÑSUÉ±Ç iÉÑ aÉqpÉÏUÇ rÉ̲mÉÉÌOûiÉqÉç || (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.
Chapter 3.3 Seevana karma
12 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
Chapter 3.3 Seevana karma
13 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.3 Seevana karma
14 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
iÉѳÉxÉåuÉlÉÏ:
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.
Chapter 3.3 Seevana karma
15 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 3.3 Seevana karma
16 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
mɶÉÉiÉç 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
37 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
38 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
39 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
40 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
41 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
42 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
43 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
44 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
45 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
46 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
47 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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 .
Chapter 4.2 Observations
48 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
49 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
50 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
Chapter 4.2 Observations
51 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
Chapter 4.2 Observations
52 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
53 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
54 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
55 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
56 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
57 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
58 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
59 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
60 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
Chapter 4.2 Observations
61 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
62 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
63 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 4.2 Observations
64 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
35 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
36 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
65 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 5 Discussion
66 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
Chapter 5 Discussion
67 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 5 Discussion
68 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 5 Discussion
69 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 5 Discussion
70 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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
71 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Chapter 6 Summary & conclusion
72 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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).
Chapter 6 Summary & conclusion
73 Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract
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.
Bibliography
74
BIBLIOGRAPHY
1. Ed.vaidya Pandit Ramachandrashastri Kinjwadekar, Astanga Sangraha of Sri
Vagbhattavirachita Sarirasthanam, 2nd edition, 1990, Sri Sataguru Publication.Pp130:22
2. Sushrutha , Sushrutha samhita with Nibandhasangraha Commentry of Sri
Dalhanacharya, Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition:2007,
Chaukhambha Orientalia, Varanasi,Pp824
3. Sharma Priyavat, History of Medicine in India, 2nd edition, 1992, Published by Indian
National Science Academy New Delhi. Pp527:3
4. Sharma Priyavat, History of Medicine in India, 2nd edition, 1992, Published by Indian
National Science Academy New Delhi. Pp527:6
5. Sharma Priyavat, History of Medicine in India, 2nd edition, 1992,published by Indian
National Science Academy New Delhi, Pp527:13,24-25
6. Sharma Priyavat, History of Medicine in India, 2nd edition,1992,Published by Indian
National Science Academy New Delhi.Pp527:5,95,118,129,142,102
7. Agnivesha , Charaka samhita with Chakrapani commentary , Edited by Vaidya Jadavaji
Trikamaji Acharya , Reprinted edition 2007,Chaukambha orientalia,Varanasi.Pp738:594
8. Agnivesha , Charaka samhita with Chakrapani commentary , Edited by Vaidya Jadavaji
Trikamaji Acharya , Reprinted edition 2007,Chaukambha orientalia,Varanasi.Pp738:594
9. Sushrutha , Sushrutha samhita with Nibandhasangraha Commentry of Sri
Dalhanacharya, Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition:2007,
Chaukhambha Orientalia, Varanasi,Pp824:42
10. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha
Orientalia, Varanasi,Pp824:19
11. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha
Orientalia, Varanasi,Pp824:118
Bibliography
75
12. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi,Pp824:118
13. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi,Pp824:119
14. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi,Pp824:39
15. Vagbhatacharya ,Astangahridayam with Sarvangasundara commentary of Arunadatta and
Ayurvedarasayana of Hemadri collated by late Dr.Anna Moreshwara Kunte and
Ramachandra Shastri Navare,Edited by Bhishagacharya Harishastri Paradakara Vaidya,
Reprint 9th Edition 2005,Chaukambha Orientalia, Varanasi.Pp956:348
16. Vagbhatacharya, Astangahridayam with Sarvangasundara commentary of Arunadatta and
Ayurvedarasayana of Hemadri collated by late Dr.Anna Moreshwara Kunte and
Ramachandra Shastri Navare,Edited by Bhishagacharya Harishastri Paradakara Vaidya,
Reprint 9th Edition 2005,Chaukambha Orientalia, Varanasi.Pp956:348
17. Bhela samhita, Edited by Girijadayalu Suklah,1999, Published by Chaukambha
Visvabharathi,Varanasi.Pp285:227,176
18. Edited by D.Keith Edmonds, Dewhurst’s textbook of obstetrics and gynaecology for
postgraduates, 6th edition 1999, Published by b Blackwell science.Pp:308
19. Stuart Campbell Christoph lees, Obstetrics by Ten Teachers, 17th edition, 2000,
Published by ASTRAZeneca. Pp374:282-285
20. Edited by D.Keith Edmonds, Dewhurst’s textbook of obstetrics and gynaecology for
postgraduates, 6th edition 1999, Published by b Blackwell science.Pp:308
21. Stuart Campbell Christoph lees, Obstetrics by Ten Teachers, 17th edition, 2000,
Published by ASTRAZeneca. Pp374:282-285
22. Stuart Campbell Christoph lees, Obstetrics by Ten Teachers, 17th edition, 2000, Published
by ASTRAZeneca. Pp374:282-285
Bibliography
76
23. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi,Pp824:40
24. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:40
25. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:40
26. Shabda kalpadruma by Raja Radakantadeva,5th volume, Published by Nag publishers,
Delhi.Pp555:361
27. Amara simha of Amarakosa or Namalinganusasana with the Ramasrami commentary of
Bhanuji Diksita, edited by Pt.Haragovinda sastri, 4th edition 2001, Chaukhambha
Publications, NewDelhi.Pp668:526
28. M.Monier –Williams, A Sanskrit English Dictionary,2005 edition, Published by Motilal
Banarsidass Publishers,Delhi.Pp1333:1218
29. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:43
30. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:38
31. Vagbhatacharya, Astangahridayam with Sarvangasundara commentary of Arunadatta
and Ayurvedarasayana of Hemadri collated by late Dr.Anna Moreshwara Kunte and
Ramachandra Shastri Navare,Edited by Bhishagacharya Harishastri Paradakara Vaidya,
Reprint 9th Edition 2005,Chaukambha Orientalia, Varanasi.Pp956:320
32. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:118,401
33. Vagbhatacharya, Astangahridayam with Sarvangasundara commentary of Arunadatta
and Ayurvedarasayana of Hemadri collated by late Dr.Anna Moreshwara Kunte and
Bibliography
77
Ramachandra Shastri Navare,Edited by Bhishagacharya Harishastri Paradakara Vaidya,
Reprint 9th Edition 2005,Chaukambha Orientalia, Varanasi. Pp956:348
34. Agnivesha, Charaka Samhita with Chakrapani commentary, Edited by Vaidya Jadavaji
Trikamaji Acharya, Reprinted edition 2007, Chaukambha orientalia, Varanasi.Pp738:594
35. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:118
Vagbhatacharya, Astangahridayam with Sarvangasundara commentary of Arunadatta and
Ayurvedarasayana of Hemadri collated by late Dr.Anna Moreshwara Kunte and
Ramachandra Shastri Navare,Edited by Bhishagacharya Harishastri Paradakara Vaidya,
Reprint 9th Edition 2005,Chaukambha Orientalia, Varanasi. Pp956:34
36. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:118,119
Vagbhatacharya, Astangahridayam with Sarvangasundara commentary of Arunadatta and
Ayurvedarasayana of Hemadri collated by late Dr.Anna Moreshwara Kunte and
Ramachandra Shastri Navare,Edited by Bhishagacharya Harishastri Paradakara Vaidya,
Reprint 9th Edition 2005,Chaukambha Orientalia, Varanasi. Pp956:348
37. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:119
38. Dr. M.Ram sundar rao, Shalya Tantra Vignanam,3rd edition,2006.Pp818:241,242
39. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:119
40. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
Varanasi, Pp824:119
Bibliography
78
41. Vagbhatacharya, Astangahridayam with Sarvangasundara commentary of Arunadatta and
Ayurvedarasayana of Hemadri collated by late Dr.Anna Moreshwara Kunte and
Ramachandra Shastri Navare,Edited by Bhishagacharya Harishastri Paradakara Vaidya,
Reprint 9th Edition 2005,Chaukambha Orientalia, Varanasi. Pp956:349
42. A.K.Dutta , Essentials of Human Anatomy,7th Edition 2006, part -1,Published by Current
Books International Kolkata.Pp380:327
43. A.K.Dutta , Essentials of Human Anatomy,7th Edition 2006, part -1,Published by Current
Books International Kolkata.Pp380:328
44. A.K.Dutta , Essentials of Human Anatomy,7th Edition 2006, part -1,Published by Current
Books International Kolkata.Pp380:336
45. A.K.Dutta , Essentials of Human Anatomy,7th Edition 2006, part -1,Published by Current
Books International Kolkata.Pp380:337
46. B.D.Chaurasia’s Human Anatomy, volume 2, 5th Edition 2000, CBS Publishers and
Distributors,New Delhi.Pp374:324
47. A.K.Dutta , Essentials of Human Anatomy,7th Edition 2006, part -1,Published by Current
Books International Kolkata.Pp380:337
48. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:7
49. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:10,11
50. A.K.Dutta , Essentials of Human Anatomy,7th Edition 2006, part -1,Published by Current
Books International Kolkata.Pp380:155
51. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:12
52. B.D.Chaurasia’s Human Anatomy, volume 2, 5th Edition 2000, CBS Publishers and
Distributors,New Delhi.Pp374:285
53. F.Gary Cunningham, Norman F.Gant, Williams Obstetrics, 21st edition,Published by
McGRAW-HILL.Pp1668:37,38
54. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:423-424
Bibliography
79
55. Dewhurt’s textbook of obstetrics and gynaecology for Postgraduates, edited by D.keith
Edmonds, 6th Edition, Published by bBell science.Pp622:308-310
56. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:567
57. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:568
58. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:424
59. F.Gary Cunningham, Norman F.Gant, Williams Obstetrics, 21st edition,Published by
McGRAW-HILL.Pp1668:325
60. Munro kerr’s Operative obstetrics, 10th edition 2000, Published by bailliere tindall.
Pp508:786
61. Obstetrics by Ten teachers, Edited by Stuart Campbell Christoph lees, 17th
Edition,Published by Astrazeneca.Pp374:283
62. Myles Textbook of Midwives, edited by V.Ruth Bennett, linda K.Brown, 13th edition,
2001, Published by Churchill Livingstone.Pp1031:460-463
63. K.Rajgopal shenoy, Manipal manual of Surgery, 2nd Edition, 2007, Published by CBS
publishers & distributors, New delhi.Pp827:2-4
64. Bailey & Love’s short practice of surgery, Revised by Charles V.mann, 22nd
edition,1996, Published by elbs.Pp1041:8-16
65. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:556
66. Dewhurt’s textbook of obstetrics and gynaecology for Postgraduates, edited by D.keith
Edmonds, 6th Edition, Published by bBell science.Pp622:308
67. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:567
68. F.Gary Cunningham, Norman F.Gant, Williams Obstetrics, 21st edition,Published by
McGRAW-HILL.Pp1668:326
69. D.C.Dutta, Text Book of Obstetrics including Perinatology and Contraception,4th Edition
2000, Published by New Central Book Agency, Calcutta.Pp705:457
Bibliography
80
70. Bhavaprakasha of Sri bhavamishra, edited by Bhishagratna Pandit Sri Brahma Sankara
Misra, part 3, 8th edition,2003, Published by Chaukhambha publications, New
Delhi.Pp836:464
71. Sushrutha, Sushrutha samhita with Nibandhasangraha Commentry of Sri Dalhanacharya,
Edited by Vaidya Jadavaji Trikamaji Acharya, 9th edition 2007, Chaukhambha Orientalia,
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
75. Vagbhatacharya, Astangahridayam with Sarvangasundara commentary of Arunadatta and
Ayurvedarasayana of Hemadri collated by late Dr.Anna Moreshwara Kunte and
Ramachandra Shastri Navare,Edited by Bhishagacharya Harishastri Paradakara Vaidya,
Reprint 9th Edition 2005,Chaukambha Orientalia, Varanasi. Pp956:349
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 –
81
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.
83
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
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