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Lacerations seevana psr
Lacerations seevana psr
Lacerations seevana psr
Lacerations seevana psr
Lacerations seevana psr
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Clinical study on utility of different types of seevana karma in episiotomy, lacerations of genital tract, Prathima, Department of post graduate studies in Prasooti Tantra & Stree roga, S. D. M. …

Clinical study on utility of different types of seevana karma in episiotomy, lacerations of genital tract, Prathima, Department of post graduate studies in Prasooti Tantra & Stree roga, S. D. M. COLLEGE OF AYURVEDA, UDUPI

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  • 1. “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 theRajiv 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 CO-GUIDE GUIDE Dr. SUCHETHA., M.D. (Ayu)Dr. USHA.V.N.K., M.D. (Ayu) Lecturer, Professor & H.O.D., S. D. M. C. A., Udupi S. D. M. C. A., Udupi S. D. M. COLLEGE OF AYURVEDA, UDUPI 2010 - 2011
  • 2. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE CERTIFICATE BY THE GUIDEThis is to certify that the dissertation entitled “CLINICAL STUDY ON UTILITY OFDIFFERENT TYPES OF SEEVANA KARMA IN EPISIOTOMY,LACERATIONS OF GENITAL TRACT” is a bonafide research work done byDr. Prathima in partial fulfillment of the requirement for the degree of M.S. (Ayu) inPrasooti Tantra and Stree roga. Date: GUIDE Place: Udupi Dr. Usha. V.N.K. M.D. (AYU) Professor & H.O.D., S. D. M. C. A., Udupi
  • 3. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE DECLARATIONI hereby declare that this dissertation entitled “CLINICAL STUDY ON UTILITY OFDIFFERENT TYPES OF SEEVANA KARMA IN EPISIOTOMY,LACERATIONS OF GENITAL TRACT” is a bonafide and genuine research workcarried by me under the guidance of Dr. V.N.K. Usha. Professor, H.O.D, andco-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.
  • 4. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES CERTIFICATE BY THE CO GUIDEThis is to certify that the dissertation entitled “CLINICAL STUDY OF UTILITY OFDIFFERENT TYPES OF SEEVANA KARMA IN EPISIOTOMY,LACERATIONS OF GENITAL TRACT” is a bonafide research work done byDr. Prathima in partial fulfillment of the requirement for the degree of M.S. (Ayu) inPrasooti Tantra and Stree Roga. Date: CO-GUIDE Place: Udupi Dr.SUCHETHA, M.D. (Ayu) Lecturer, S. D. M. C. A., Udupi
  • 5. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES ENDORSEMENTThis is to certify that the dissertation entitled “CLINICAL STUDY ON UTILITY OFDIFFERENT TYPES SEEVANAKARM IN EPISIOTOMY, LACERATIONS OFGENITAL TRACT” is a bonafide research work done by Dr. Prathima under theguidance of Dr. V.N.K. Usha, Professor, H.O.D. and co guidance ofDr. Suchetha, Lecturer, Dept.of Prasooti Tantra and Stree Roga, S. D. M. College ofAyurveda, Udupi. .H. O. D. PRINCIPALDr.V.N.K.Usha Dr. U.N.PRASAD (M.D.Ayu) S.D.M.C.A. UdupiDept. of Prasooti Tantra and Stree roga Date:S.D.M.C.A. Udupi Place: Udupi
  • 6. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES COPY RIGHTI hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka shallhave the rights to preserve, use and disseminate this dissertation/ thesis in print orelectronic format for academic / research purpose. Date: Dr. Prathima Place: Udupi B.A.M.S.
  • 7. Acknowledgement     ACKNOWLEDGEMENTCompletion of dissertation work is the hallmark in postgraduate studies.At this junction myhead bows down with great humility in the feet of almighty, without inspiration,I would nothave 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.Premkumar, and Mrs. Bharathi and Grandmother Mrs. Lalithamma for showering their blessingsand 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 ofAyurveda,Udupi. In this regard, I would like to express my heartfelt gratitude to honourableDr.D.Veerendra Hegde, Dharmadhikari, Shri kshetra Dharmasthala, and president of S.D.M.SocietyI genuinely feel that any words of gratitude are not sufficient to express my humble thanks tomy proficient guide Dr.V.N.K.Usha, Professor and HOD of Dept. of Prasooti tantra andStreeroga, SDM College of Ayurveda. Her excellent guidance, moral support & suggestionsduring 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 duringthe course of my work.My sincere gratitude & thanks to Dr.Mamatha K.V.,Asst.professor, Dept. of Prasooti tantraand Streeroga, SDM College of Ayurveda,Kuthpady , for her suggestions.My sincere gratitude & thanks to Dr.Ramadevi G.Asst.professor, Dept. of Prasooti tantraand Streeroga, SDM College of Ayurveda,Kuthpady , for her suggestions.I express my regards to Dr.Vidya Ballal for her suggestions and help.
  • 8. Acknowledgement    I am greatful to Dr.U.N.Prasad, Principal,S.D.M. College for his invaluable support andguidance for the completion of this thesies.My deep sense of gratitude to Dr.Govinda Raju Dean of P.G. Studies and Dr.PrabhakarRenjol 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 hisgenerous 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 supportthroughout my study.I thank all those who have directly or indirectly contributed to the successful completion of thiswork, still I apologize for errata and shortcomings. Dr.Prathima
  • 9.                Dedica    ted to   my   parents
  • 10. LIST OF ABBREVIATIONSA.S. – Astanga SangrahaSu.Sa. – Sushrutha SamhitaA.H. – Astanga Hridaya& _ and% _ PercentageNo. _ Number of patientsPt. _ Patients
  • 11. ABSTRACTTitle: “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 beforecan create self reliance in practicing surgical techniques and for planning further surgicalprocedures. The process of delivery can be made easy by yoniprasarana (dilating vulval orifice),by surgical intervention Utkartana karma which was forwarded as an established surgicalpractice. In contemporary age, the “Episiotomy” is performed to cut short the second stage oflabour and to decrease the trauma to the vaginal tissue. For repairing these wounds differentseevana karma are mentioned in our classics. Aghata, Abhigata & Utkartana require seevana. Agood suturing procedure immediately ensures haemostasis, healthy healing, prevents infectionand in long run preserves the integrity of the pelvic floor. Seevana karma is one among theAstavidha shastra Karmas described in classics. There are four types of seevana karmamentioned 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 seevanakarma 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 fromIPD of S.D.M. Ayurveda hospital, Kuthpady, Udupi, according to inclusive criteria wereregistered for the study. The seevana vidhi is observed with results & the utility of seevana vidhiis evaluated.
  • 12. 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 byvellitaka 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 thepatient is minimal and left with fine scar within 15 days. In all patients healing was good.Keywords: Seevana karma, Utkartana, Vrana, Episiotomy 
  • 13. CONTENTSCHAPTER TITLE PAGE NO.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. 3.3 seevana karma 10-16 3.4 Anatomy 17-22 3.5 Disease review 23-34 Clinical study 4.1 Materials and Methods 35-36 4. 4.2 Observations 37-64 65-70 5 Discussion 71-73 6 Summary and conclusion 7 Bibliography 74-80 8 Annexure 81-84
  • 14. LIST OF FIGURESSerial 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
  • 15. LIST OF GRAPHSGRAPH 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 47 11. Distribution acc. to Sattva 48 12. Distribution acc. to Samhanana 49 13. Distribution acc.to Satmya 50 14. Distribution acc.to Aharashak.. 15. Distribution acc. to Vyayamash. 51 52 16. Incidence of suturing in skin 53 17. Incidence of suturing in muscle
  • 16. 18. Incidence of suturing in Mucous 5419. Incidence of suturing tech.in lacerat 5520. Incidence of complication 5621. Incidence of haemotoma 5722. Intensity of pain 6023. Incidence of Resuturing 6124. Incidence of suture absorption 6225. Incidence of wound healing on 15th 6326 Incidence of wound healing on 30th 64
  • 17.    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
  • 18.    55 21. Suturing pattern in Lacerations 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.
  • 19. Chapter 1 Introduction    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 inmedicine but is enriched in surgical field too. Acharya Sushrutha is the epitome of ancient Indian surgery which expounds theconcepts and skill in surgery prevalent at that time. He has explained about basic principles ofsurgery, surgical procedures etc. upto the plastic surgery hence known as Father of Surgery. Heexplained 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 vulvalorifice (A.S) 1. One such surgical intervention is Utkartana karma mentioned in Mudhagarbhachikitsa (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 ofepisiotomy, 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 ofvarious parts that occur during delivery. Various degrees of tears involving maternal passagemay cause immediate complications like haemorrhage, infection, wound dehiscence & remotecomplications like urine incontinence, prolapse of organs. 1  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital  tract     
  • 20. Chapter 1 Introduction    Seevana karma is one of the Shastra karma mentioned by Caraka, Sushrutha &Vagbhata. Acharya Sushruta has mentioned 4 different types of seevana karma along with itsindication, contraindication, suture material & procedure in detail. Restoring Ayurvedicterminology which was described centuries before, in routine contemporary practicalinterventions can cause self reliance in surgical practice and planning further surgicalprocedures. Hence present study of “evaluating efficacy of different types of Seevana karma in repairof episiotomy, lacerations of genital tract” has been planned.  2  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital  tract     
  • 21. Chapter 2 objectives  OBJECTIVES OF THE STUDY • Conceptual study on utility of Ashtavidha shastra karma in Prasooti tantra & Stree roga. • Conceptual study of seevana karma with its classification & method of its application. • Analysis of different types of seevana karma in repairing of Episiotomy, Lacerations of genital tract.  3  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 22. Chapter 3.1  Historical review                                                            HISTORICAL REVIEW Preservation of health has been instinctive necessity of mankind from the beginning ofcreation. So, Acharya Charaka has said, Ayurveda as beginingless and eternal. AcharyaSushrutha 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 eyedneedles. In 30 AD, the Roman Celsus again described the use of sutures and clips, and Galenfurther described the use of silk and catgut in 150 AD. Description of ligatures used forhaemostasis, 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 ofpig bristles in infected wounds. Surgical and suture technique evolved in the late 1800s with thedevelopment of sterilization procedures. Finally, modern methods created uniformly sizedsutures.Pre – Vedic period: Some surgical measures were also practiced is inferred from the findings of trephinedhuman skulls and curved knives in excavation.4Vedic 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 showthat plastic surgery is also performed. 4  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 23. Chapter 3.1  Historical review  The most popular and expert physicians were twin Ashvins whose marvelous medicaland surgical feats described in the Rig-Veda, indicated position of the healing art in that oldendays.Post vedic period:6 Amongst epics and Puranas, Mahabharatha has got references of surgery performed inobstructed labour.          The Ramayana and Mahabharata and Puranas are valuable treasures and records of Indianculture, because of their encyclopedic character, contain a lot of information on medicineprevalence in those days.  In Matsyapurana, abnormalities of delivery and deformity of fetus are mentioned. Mahavagga, in the book (6) on medicaments, gives valuable information regardingdisease and treatment. Surgical operation of wounds and abscess were done and they were treated withbandaging, dusting, fumigation etc. Jaina tradition mentioned about different types of treatment with its indication. Surgicaloperation with sharp instruments, treatment by charmas and drugs were prevalent. In Kautilya arthashastra, Physicians also accompanied the military expedition, dulyequipped 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 itsclassification, colour of discharge. Later, described about six types of surgical operations7, in thisseevana also one among and mentioned about its indication8. All operative maneuvers carried out by the present day surgeon involve one or more ofthese techniques only and not anything beyond these. 5  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 24. Chapter 3.1  Historical review  Sushrutha is the first person to evolve and introduce experimental surgery for trainingstudents9. He has described the merits and demerits of all instruments, their proper maintenanceand correct method of use etc, which reflect his expertise. The Indian plastic surgeon, Sushrutha (AD c380-c450), described suture material madefrom flax, hemp, and hair. At that time, the jaws of the black ant were used as surgical clips inbowel surgery. In Sushrutha samhita, described about sharp and blunt instruments along with parasurgical 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, mentionedabout seevana karma17.Modern view: Joseph Lister introduced great change in suturing technique. He first attemptedsterilization 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 intoproduction of numerous absorbable and non-absorbable materials. The first synthetic absorbable was based on polyvinyl alcohol in 1931. Polyesters weredeveloped in the 1950s, and later the process of radiation sterilization was established for catgutand polyester. Polyglycolic acid was discovered in the 1960s and implemented in the 1970s. 6  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 25. Chapter 3.1  Historical review  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 todayapproximately 50,000 women give birth each year and of these 5, 25,000{70%} will sustainperineal trauma and will require stitches19. It was then in 1918 by Pomeroy thought all primigravida should receive an episiotomy toprotect the fetal head and the pelvic floor20. The majority of the woman will experience perineal pain in the following delivery andover 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 20yrshas 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 complicationaffecting relatively small numbers of women.More recent work shown that unrecognizedcomplete disruption of the anal sphincter is much more common than this long term incontinenceaffects 5% of women22.  7  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 26. Chapter 3.2 Introduction of Shastra karma  ASHTAVIDHA SHASTRA KARMA Acharya sushrutha classified instrument under 2 heading i.e. sharp instrument and bluntinstrument. Blunt instrument used to remove foreign body which is easily available, whereassharp instrument were utilized for eight surgical procedures, in different diseases and procedures. Table no.1Sushruta Su. 5/5 Charaka Chi. 25/55 Vagbhata Su. 26/28Chedana Chedana ChedanaBhedana Patana BhedanaLekhana Lekhana LekhanaVedhana Vyadhana VyadhanaEshana EshanaAaharanaVisraavana Prachaana PrachaanaSeevana Seevana Seevana Utpaatya Apaatya Grahana Kuttana , manthana , dahana 8  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 27. Chapter 3.2 Introduction of Shastra karma vÉx§É mÉÉrÉlÉ ÌuÉÍkÉ:23 Tempering should be done in 3 ways, • Alkalies should be used for excising arrow pieces and bone. • Water should be used for excising, incising and splitting muscles. • Oil should be used in puncturing veins and excising ligaments.  vÉx§É xÉqmÉiÉç :24             It should be convenient to hold in hand, made up of good metal, must have fine and sharpedge, and attractive in appearance, all the parts of instrument must be well setup, designedproperly.vÉx§É SÉãwÉ :25 It should not be blunt, broken, broken blade, too long, unusually short, unusually bulky,and very small.  9  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 28. Chapter 3.4 Anatomy   CERVIX The cervix is a constricted part of uterus separated from the body by the constriction partknown 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 anteriorwall 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 iliacgroups and sacral groups. 17  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 29. Chapter 3.4 Anatomy   The vagina It is the fibromusculo – membranous sheath communicates uterine cavity with exterior atthe 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 thirdis 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 ------thesetogether form azygous vaginal arteries. Venous drainage into internal iliac vein, posterior vaginal wall forms vaginal and superiorrectal 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..                                                                                                                                18  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 30. Chapter 3.4 Anatomy  Nerve supply:47  Sympathetic and parasympathetic supply from the pelvic plexus and lower part is by thepudendal 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. 19  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 31. Chapter 3.4 Anatomy   The Perineum It includes all structure which occupies the pelvic outlet and lie below the pelvic diaphragm. The region at the lower end of the trunk, in the interval between the two thighs, where the external genitalia are located is called perineum. The pelvic outlet is a diamond shaped space and it presents boundaries49 : o In front: lower border of symphysis pubis and arcuate pubic ligament. o Behind: tip of the coccyx. o Anterolaterally: ischiopubic rami and ischial tuberosities. o Posterolaterally: Sacrotuberous ligament covered by the gluteal maximus.Divisions: 50 A transverse line joining the anterior parts of the ischial tuberosities and passingimmediately anterior to the anus, divides the perineum into 2 trianglar areas, a posterior analregion or triangle An anterior urogenital region or triangleAnal 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: 51It is the anterior part of the pelvic outlet. The urogenital is closed by the following structuresi.e.from below upwards {superficial to deep} a. Skin b. Fatty layer of superficial fascia. 20  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 32. Chapter 3.4 Anatomy   c. Membranous layer of superficial fascia or fascia of colles. d. Contents of the superficial perineal pouch. e. Perineal membrane {inferior fascia of urogenital diaphragm}     f. Contents of the deep perineal pouch. g. Superior fascia of urogenital diaphragm.The superficial perineal pouch is formed by the deep layer of the superficial perineal fascia andinferior 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 urogenitaldiaphragm. Between the layers, there is a potential space of about 1.25cm. The contents are deeptransverse perinea and sphincter urethrae membranaceae. Both the pouches contain vessels andnerves.Perineal body:52 The perineal body, or the central point of the perineum, is a fibromuscularnode situated in the median plane, about 1.25cm infront of the anal margin and close to the bulbof the vestibule. The pyramidal shaped tissue where the pelvic floor and the perineal muscles and fasciameet 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 withrectovaginal septum.Nerve supply: Perineal branch of pudendal nerve.                                   21  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 33. Chapter 3.4 Anatomy  Actions of the urogenital diaphragm: I. Supports the bladder. II. Constricts the vagina. III. Fixes the perineal body.IV. Sphincter urethra exerts voluntary control of micturation and expels the last drops of urine after the bladder stops contraction Pudendal nerve • It is the nerve of the perineum and of the external genitalia and is accompanied by internal pudendal vessels. • It arises from sacral plexuses in the pelvis and is derived from spinal nerves S2, 3, 4.Branches: 53 • Inferior rectal nerve. • Perineal nerve.Applied anatomy:The pudendal nerve supplies sensory branches to the lower one inch of the vagina, through theinferior rectal and posterior labial branches.In some conditions55, pudendal nerve block given. A 20ml syringe, one 15cm 17-20 gauze spinalneedle is placed on the tip of the ischial spine of one side and pierces in the vaginal wall on theapex of ischial spine and pushes little to pierce the sacrospinous ligaments just above the ischialspine tip, after aspirating blood, solution is injected.  22  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 34. Chapter 3.5 Disease review   PERINEAL TEAR Due to extension of episiotomy, posteriory it involves the anal sphincter from back &obliquely upwards into the lateral vaginal wall.Condition favoring laceration include54 – o Delivery of a large fetus. o Malpresentations / Malpositions especially if instrumental rotation is performed. o Delivery through narrow pubic arch.Three degrees of perineal tear: 55 In the first degree, there is a laceration of skin & an exposure of superficial muscle tissue. In the second degree, there is tearing of the muscle of the pelvic floor. In the third degree, anal sphincter & anal wall are disrupted. Central tear involves lower end of the posterior vaginal wall and extends into peritoneum or even rectum. 23  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 35. Chapter 3.5 Disease review  First & second degree tears56:-Spontaneous tears originate near the midline of the perineum, but when they are traced upwardsthey 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. 24  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 36. Chapter 3.5 Disease review  Second degree: The vaginal mucosa is to be sutured first. The first suture is placed at or just above theapex of the tear. Thereafter, the vaginal walls are opposed by interrupted sutures with chromiccatgut 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 tornends of the sphincter ani externus are sutured with figure of eight stitch by another interruptedsuture. Perineal skin by interrupted suture 25  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 37. Chapter 3.5 Disease review   EpisiotomyDefinition: It is an incision on the perineum & the posterior vaginal wall during the second stage oflabour 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. In1983, Thacker and Banta reported that about 2/3rd of all vaginal deliveries in US are associatedwith performance of episiotomy. In 1987, Reynold and yudkin reported 28% decrease in the frequency of episiotomy overa period of 4yrs. In the review of 20,000 women who underwent vaginal delivery, Owen andHanth reported that approximately 2/3rd of the primigravidas and 1/3rd of the multiparous hadepisiotomies.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.                            26  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 38. Chapter 3.5 Disease review  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. -relative safety from rectal -blood loss is least. involvement from extension. -repair is easy. -postoperative comfort is -if necessary, the incision can maximum. be extended. -healing is superior. -Wound disruption is rare. -Dypareunia is rare. 27  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 39. Chapter 3.5 Disease review   Demerits : -Apposition of the tissues is -Extension, if occurs not so good. involves rectum. -Blood loss is little more. -Not suitable in -Relative increased incidence manipulative delivery or in of wound disruption. abnormal presentation or -Dyspareunia is more. position. 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. 28  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 40. Chapter 3.5 Disease review  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. 29  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 41. Chapter 3.5 Disease review  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’.                                                   30  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 42. Chapter 3.5 Disease review   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 & afterthird 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.                              31  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 43. Chapter 3.5 Disease review   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. 32  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 44. Chapter 3.5 Disease review  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. 33  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 45. Chapter 3.5 Disease review  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.    34  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 46. Chapter 3.3 Seevana karma    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. Suturesmust 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 topractical work. One even having acquired great learning is unfit for the profession if he has notdone the practical work. Suturing should be practiced in two ends of fine and thick cloth andsoft skin.Whereas Dalhana mentioned mrudu charma as mamsa pesi and mamsa varti.   10  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 47. Chapter 3.3 Seevana karma    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 itshould 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, diseasescaused 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, ulcerslocated on the head, nose, Lips, cheeks, buttocks etc; which are located in fleshy and immovableparts are sutured. 11  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 48. Chapter 3.3 Seevana karma   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., bykeeping the torn and hanging pieces of muscles in their proper places, placing joints and bones intheir 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 2fingers 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 ofthe jati flower. xÉÏuÉlÉ mÉëMüÉU 37, 38 Vellitaka Gophanika Tunnasevanee Rujugranthi 12  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 49. Chapter 3.3 Seevana karma   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.            13  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 50. Chapter 3.3 Seevana karma    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 / subcuticularsuture.   The running subcuticular suture is a buried form of the running horizontal mattresssuture. It is placed by taking horizontal bites through the papillary dermis on alternative sidesof the wound. The running subcuticular suture is begin by placing the needle through one wound edgeand enters into the defect. The opposite edge is held firmly with a skin hook as the needle ispassed in a horizontal pattern through the mid dermis. It exits with a 1/2 cm. pass and then isbrought in approximation to the opposite wound side and enters the mid dermis. This is repeatedon alternate sides of the wound as the suture is advanced down the wound edge. The suture canbe 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 inwhich 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, thedead space has been eliminated, and the best possible cosmetic result is desired. The suture does not provide significant wound strength, although it does preciselyapproximate the wound edges. Therefore, the running subcuticular suture is best reserved forwounds in which the tension has been eliminated with deep sutures, and the wound edges are ofapproximately equal thicknesses. 14  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 51. Chapter 3.3 Seevana karma    HeÉÑaÉëÎljÉ:- Straight knot & / is known as interrupted suture. In this individual sutures are separatedfrom 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 theepidermis and the full thickness of the dermis, and existing perpendicular to the epidermis on theopposite side of the wound. The 2 sides of the stitch should be symmetrically placed in terms ofdepth and width. Grasping the end of the suture with a pair of forceps and the opposite side with a needleholder, 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 tensilestrength, 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 andthe 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. 15  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 52. Chapter 3.3 Seevana karma   Precaution: - 39 Suture should not be put neither too far nor too near as the former would cause pain whilethe 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 ofpriyangu, anjana, madhuyasti & lodhra or that of sallaki fruit or ash of linen should be sprinkledall 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.                                                       16  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 53. Chapter 4.2  Observations  OBSERVATION01. Distribution of patients according to age:  Table no.3        Age   No.  %    (In years)        20‐25  19  38        26‐30  26  52        31‐35  4   8         36‐40  1  2  Graph no.1 Age disribution 60 50 40 20‐25 30 26‐30 31‐35 20 36‐40 10 0 no  % Among 50 patients, 52% in 26-20 yrs, 38% of patients were in the age group of 20-25yrs, 8% in 31-35 yrs and 2% in 36-40yrs. 37  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 54. Chapter 4.2  Observations 02. Distribution of patients according to religion: Table no.4 Religion No. % Hindu 35 70 Muslim 14 28 Christian 1 2 Graph no.2 80 Religion distribution 70 60 50 hindu 40 muslim 30 christian 20 10 0 no  %Among 50 patients, 70% patients belong to Hindu religion, 28% to Muslim and 2% to Christian. 38  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 55. Chapter 4.2  Observations  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 S-E status distribution 80 70 60 50 upper  40 middle 30 lower 20 10 0 no %Among 50 patients, 70% belong to middle class, 20% patients belong to upper middle class, and10% patients belong to lower middle class. 39  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 56. Chapter 4.2  Observations 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 occupation distribution 100 90 80 70 60 H.W 50 40 teacher 30 tailor 20 10 0 no %Among 50 patients, 86% patients were Housewife, 8% were teacher and 6% were tailor. 40  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 57. Chapter 4.2  Observations  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. 41  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 58. Chapter 4.2  Observations 06. Distribution of patients according to Education: Table no.8 Education No. % Primary 20 40 High school 7 14 Graduate 23 46 Graph 6 Education distribution 50 45 40 35 30 primary 25 20 high sch 15 graduate 10 5 0 no % Among 50 patients, 46% were graduated, 40% were from primary school, and 14% werefrom high school. 42  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 59. Chapter 4.2  Observations 07. Distribution of patients according to parity: Table no.9 Parity No. % Primigravida 31 62 Multipara 19 38 Graph 7 Parity distribution 70 60 50 40 primi 30 mutli 20 10 0 no. % Among 50 patients, 62% patients were primigravida and 38% patients were multipara. 43  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 60. Chapter 4.2  Observations 08. Distribution of patients according to diet history: Table no.10 Diet No. % Vegetarian 18 36 Mixed 32 64 Graph no.8 Diet distribution 70 60 50 40 veg 30 mixed 20 10 0 no % Among 50 patients, 64% were having mixed diet and 36% were vegetarian. 44  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 61. Chapter 4.2  Observations 09. Distribution of patients according to Prakruthi: Table no.11 Prakruthi No. % Vatapitta 17 34 Vatakapha 17 34 Pittakapha 16 32 Graph no.9 Prakruthi distribution 40 35 30 25 vatapitta 20 vatakapha 15 pittakapha 10 5 0 no % Among 50 patients, 34% patients are of vatapitta and vatakapha prakruthi, 32% are ofpitta kapha prakruthi. 45  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 62. Chapter 4.2  Observations 10. Distribution of patients according to Saara: Table no.12 Saara No. % Pravara 2 4 Madhyama 45 90 Avara 3 6 Graph no.10 : Saara distribution 100 90 80 70 60 pravara 50 40 madhyam 30 avara 20 10 0 no %Among 50 patients, 90% belongs to madhyama saara, 6% belongs to avara saara and 4% belongsto pravara. 46  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 63. Chapter 4.2  Observations 11. Distribution of patient according to sattva: Table no.12 Sattva No. % Pravara 2 4 Madhyama 47 94 Avara 1 2 Graph no.10 Sattva distribution 100 90 80 70 60 pravara 50 40 madhyam 30 avara 20 10 0 no % Among 50 patients, 98% are of madhyama sattva and 2% are of avara sattva . 47  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 64. Chapter 4.2  Observations 12. Distribution of patients according to samhanana: Table no.14 Samhanana No. % Pravara 6 12 Madhyama 39 78 Avara 5 10 Graph no.12 samhanana distribution 90 80 70 60 50 pravara 40 madhyam 30 avara 20 10 0 no % Among 50 patients, 78% were having madhyama samhanana, 12% are pravara and 10%are in avara. 48  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 65. Chapter 4.2  Observations 13. Distribution of patients according to Satmya: Table no.15 Satmya No. % Pravara 12 24 madhyama 30 60 Avara 8 16 Graph no.13 Satmya distribution 90 80 70 60 50 pravara  40 madhyam 30 avara 20 10 0 no. % Among 50 patients, 60% patients belongs to madhyama , 24% belongs to pravara and16% belongs to avara. 49  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 66. Chapter 4.2  Observations 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 avaraand 2% having pravara sattva 50  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 67. Chapter 4.2  Observations 15. Distribution of patients according to vyayama shakthi: Table no.17 Vyayama No. % shakthi 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 51  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 68. Chapter 4.2  Observations 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 havingsubcuticular suture. 52  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 69. Chapter 4.2  Observations 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 ofcontinuous suture. 53  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 70. Chapter 4.2  Observations 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 Suturing pattern in mucous layer 120 100 80 60 conti. other 40 20 0 no % Among 50 patients, 100% patient’s mucous layer is sutured by continuous suture. 54  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 71. Chapter 4.2  Observations 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 tearsuturing done, 7% of cervical tear sutured and 2% vaginal tear sutured. 55  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 72. Chapter 4.2  Observations 20. Incidence of complication in different types of suturing: Table no.22 Complication No. % (wound gaping with slough) Present 5 10 Absent 45 90 Graph no.20Among 50 patients, 90% patients does not have any complications but in 10% patients gaping ofwound along with presence of slough formation noticed. 56  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 73. Chapter 4.2  Observations 21. Distribution of patient in haematoma formation after suturing: Table no. 23 Haemotoma formation No. % Present 3 6 Absence 47 94 Graph No. 21Among 50 patients, in 84% patients suture healthy, but in 6% patient haemotoma noticed. 57  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 74. Chapter 4.2  Observations 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 arehaving 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 and10% having severe pain on second day. 58  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 75. Chapter 4.2  Observations  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% havingmoderate 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% havingmoderate pain. 59  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 76. Chapter 4.2  Observations  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 60  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 77. Chapter 4.2  Observations 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. 61  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 78. Chapter 4.2  Observations 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. 62  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 79. Chapter 4.2  Observations 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 completelyhealed on 15th day, 78% patient have mattress suture, in this 20% patient wound was completelyhealed on 15th day. Remaining patient wound was healing. 63  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 80. Chapter 4.2  Observations  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.  64  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 81. Chapter 4.1   Clinical study    CLINICAL STUDYObjective 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 ingenital 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 ofselecting data is by participant observation method. A minimum of 50 patients, diagnosed under inclusive criteria will be taken. The seevanavidhi is observed with results & the utility of seevana vidhi is evaluated. A detailed proforma is prepared considering all points pertaining to history, course oflabour, 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. 35  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 82. Chapter 4.1   Clinical study   Exclusion criteria: • Past history of perineal operations. • Patients suffering from systemic disorders, hypertension, thyroid dysfunction, infections & respiratory disorders.Intervention: After the diagnosis of particular conditions, the seevana karma will be observed. Later 3groups 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 areobserved.In episiotomy , perineal laceration healing of perineal wound, tone of the perineal muscle,any tenderness during movements , difficulty in sitting down posture are assessed  36  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 83. Chapter 5   Discussion  DISCUSSION Astavidha shastra karma is the fundamental procedure for the development of surgerywhich includes chedana, bhedana, seevana etc. Episiotomy is a small incision given on the stretched perineum at the time of crowning ofhead. 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 modernobstetricians was to protect the fetal head and to preserve the integrity of the pelvic floor, toprevent 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 duringextraction of fetus, utkartana karma is mentioned as one of the procedure, this can be consideredas 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 toapproximate the cut edges so they will heal rapidly, leaving a minimal scar. Edges to be opposedand cut given in a clean line and perpendicular to the skin surface. The cut edges are broughttogether 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. 65  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 84. Chapter 5   Discussion  Mattress suture is a type of interrupted suture, it is useful in eversion of wounds, reducesthe dead space and minimizes the stretching across the wound. Suture material are divided into absorbable and non absorbable, absorbable suturematerials are catgut and polyglycolic acid. They cause less tissue reaction, having more tensilestrength & are absorbed slowly. Catgut is the oldest suture material & is made from the submucosa of sheep intestine. Absorption mainly occurs in 2 ways i.e. by enzymatic reaction and byhydrolysis. When the material starts absorbing, it loses its tensile strength. Absorbable syntheticsutures are commonly used for subcuticular wound closure and for interrupted suture in skin it isused. 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 materialstaking microorganisms into the tract. So these materials also lose tensile strength quickly withtime. Mersillin suture material cause less tissue reaction. And even nylon also causes less tissuereaction. 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 suturematerial. As paschat karma, wound should be covered with powder of priyangu, madhuyasti andlodhra are mentioned. Studies have shown that the IQ of children born after episiotomy is good compared tothat of children born without episiotomy. Without episiotomy prolonged stay of the head inperineum leads to intracranial injuries, asphyxia and mother could be affected by 3rd or 4th degreetear which is hard to repair compared with episiotomy.The demerits of the episiotomy, if extension occurs, involves rectum, relative increasedincidence of wound disruption. And also one more factor responsible for wound healing, duringpuerperal period, advised strict diet and complete rest. The rich vascularity to the region alsofavours the wound healing. The wound heals by 4-6 weeks, depending on the size of the incision and type of suturematerial used to close the wound. The mechanism of wound healing depends on certain factorsi.e. vitamin, trace elements and protein deficiency may delay the wound healing or breaks down 66  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 85. Chapter 5   Discussion the wound. Improper wound care may give rise to infection, wound dehiscence, so healing maybe 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 isafresh one.Religion: In this study, 70% belongs to Hindu religion, 28% are of Muslim and 2 % are ofChristian. 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 uppermiddle class, and 10% patients belong to lower middle class. The S.D.M. Hospital is a charityhospital 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 ofthe patient came from rural area. As the hospital is situated in the urban area, it is surrounded byseveral villages representing the rural areas. This could be the reason why patients were fromrural area.Education: In this study, 46% were graduated, 40% were from primary school, and 14% werefrom 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 wherestudy was conducted is costal area. Most of the people are doing fish business & having the sameas their main food. This gives observation that most of patient has mixed type of dietary habit. 67  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 86. Chapter 5   Discussion 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 saaraand 4% belongs to pravara. The present study on Sattva, 94% are of madhyama sattva, 4% are of pravara sattva and2% are of avara sattva. The present study on Samhanana, 78% were having madhyama samhanana, 12% arepravara and 10% are in avara. The present study is on Satmya, 60% patients belong to madhyama, 24% belongs topravara 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% arehaving 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 havingsubcuticular 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 continuoussuture. One or two sutures removed in case of infection in interrupted suture, whereas incontinuous suture whole suture removed, later it leads to wound gaping. 68  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 87. Chapter 5   Discussion Incidence of suturing pattern in mucosa: In this study, 100% patient’s mucosal layer is sutured by continuous suture. As it is easyto 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 wereprimigravidas. 12% perineal tear noticed, these are multigravida, without episiotomy, baby delivered andit was first degree perineal tear and sutured by simple suture. 7% cervical tear and 2% vaginal tear are sutured in cases of assisted deliveries byinstrumentation 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 complicationsobserved 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. Sloughformation 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 haemotomanoticed. As all of these were instrumental deliveries. Haemotoma may be due to deep cervicaltear, injury to blood vessels.Incidence of pain: In this study, 66% patients are having severe pain and 34% patients are having moderatepain on first day 54% patients are having moderate pain, 36% having mild pain and 10% having severepain on second day. 72% patients are having mild pain, 18% having absence of pain, 8% having moderatepain and 2% having severe pain on 3rd day. 69  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 88. Chapter 5   Discussion  50% patients are having mild pain, 44% having absence of pain and 2% having moderatepain on 4th day. 80% patients are having absence of pain, 16% having mild pain, and 4% having moderatepain on 5th day. Compare to interrupted suture, in subcuticular suture pain is less, patient does not feeldiscomfort for sittingIncidence of Resuturing of wound: In one multigravida patient resuturing was done as the wound spontaneously opened on3rd day probably due to anaemia and increased elasticity on perineal muscle. Later suturing wasdone. 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 dayshospital stay is not agreeable, so patients were discharged by 5th day. In the period of theirhospital 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 wascompletely healed and on 30th day thin scar was noticed. 78% patient’s undergone mattress suture, in this 20% patient’s wound was completelyhealed on 15th day. Remaining 58% patient’s suture was completely healed on 30th day.  70  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract    
  • 89. Chapter 6  Summary & conclusion    SUMMARY AND CONCLUSION The present dissertation study entitled “Clinical study on utility of different types ofseevana 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. 71  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 90. Chapter 6  Summary & conclusion    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 theAstavidha Shastra karma, & it is one of the Vranashasti upakrama. Utkartana karma which ismentioned in Mudhagarbha chikitsa describes about an incision. Episiotomy is performed to cutshort the 2nd stage of labour and to prevent perineal injuries. Suturing of the different layers ofepisiotomy 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). 72  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 91. Chapter 6  Summary & conclusion   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.            73  Evaluating efficacy of different types of seevana karma in episiotomy, lacerations of genital tract      
  • 92. Bibliography    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 th Dalhanacharya, Edited by Vaidya Jadavaji Trikamaji Acharya, 9 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 74    
  • 93. Bibliography    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 75    
  • 94. Bibliography    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 76    
  • 95. Bibliography    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 77    
  • 96. Bibliography    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 78    
  • 97. Bibliography    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 79    
  • 98. Bibliography    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  80    
  • 99. No. %4th 4 8 Distribution according to suture absorption th 10 205 60 th th 506 – 15 25 50 40 30 20 10 0 4th  5th  6th – 15th 
  • 100. orption No. % 6th – 15th 
  • 101. 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 –         80    
  • 102. 6. PRAJANANA VRITTANTANo. Year & date Pregnancy Method of delivery Baby8. 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:         81    
  • 103. 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.         82    
  • 104. 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&TI SCOR DILATATION(c EFFACEMENT( C STATIO CONSISTENME E m) %) x N CYVital data : AFTER2ndDELIVERY DAY 1 DAY2 DAY 3 DAY 4 DAY 5.B.P.PULSE.R.R.TEMP.H.R.         83    
  • 105. TYPE OF SUTURE –HEALING OF SUTURE : 1 2 3 4 5 1530DURATION OF 1stSTAGEDURATION OF 2ND STAGEDURATION OF 3RD STAGE b) COMPLICATION DURING LABOUR c) CONCLUSION : SIGNATURE OF THE STUDENT SIGNATURE OF THE GUIDE: SIGNATURE OF THE CO – GUIDE:         84    
  • 106.   DIFFERENT TYPES OF SEEVANA KARMA Figure no.3 Figure no.4   Rujugranthi (Interrupted suture) Vellitaka (continuous suture)             Tunnasevani (Subcuticular suture)   Figure no.5
  • 107. Episiotomy Figure no.6       Performing Episiotomy Figure no.7 Suturing of different layers of Episiotomy 
  • 108. SHASTRA KARMA OF SEEVANA KARMA Figure no.1                          Figure no.2                                                                         

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