Wondershare

PDFelement

प्रसूति िन्त्र
&
स्त्रीरोग
Paper I
PART B
 Wondershare
PDFelement

CHAPTER I: Prasava vijnana

 Prasava Paribhasha
प्रसवः गर्भ मोचनम् । (शब्दकल्पद्रु म)
Prasava literally means to release/liberate the Garbha.

The process when the woman expels the foetus is called Prasava.

 Prasava Hetu
 According to Acharya Charaka: When Shukra, Artava, Atma, Garbhashaya and
Kala are all favourable, then the fully mature foetus is born at the appropriate
time without any difficulty.
 According to Acharya Sushruta: Due to Kala (time factor), just as the ripe fruit
detaches from its stalk, similarly the mature Garbha detaches from Nadi bandha
and Prasava occurs.
 According to Acharya Harita: Due to absence of desire of Garbha to stay in
Garbhashaya, detachment takes place and Prasava occurs.
 According to Acharya Bhela: The attainment of full maturity of different body
parts by Garbha is the cause for Prasava.

 Prasava Kala
 According to Acharya Charaka & Acharya Kashyapa: After completion of 8
months, from the first day of 9th month until 10th month is considered as Prasava
Kala. Prolonged stay in Garbhashaya beyond this period is abnormal.
Acharya Chakrapani clarifies that 9th and 10th month are the best suitable time for
labour. However, in 11th and 12th month, abnormalities are less, so they can also
be considered as Prasava Kala.
 According to Acharya Sushruta & Acharya Vagbhata: Prasava Kala is the period
between 9-12 months.
 According to Acharya Harita: 10th and 11th month are considered as Prasava Kala.
 Wondershare
PDFelement

 Sutikagara / Sutikagriha
 Paribhasha:
सूतिकागृहम् इति प्रसवस्थान । (अमरकोष)
The place where Prasava is conducted is called Sutikagriha.

 Paryaya: Sutikagara, Sutikagriha, Prasava-alaya, Prasavagriha

 Nirmana Vidhi:
Acharya Charaka mentions that before Prasava Kala, a Sutikagriha is built. The
construction site and its soil should be devoid of bones, pebbles, stones, broken
earthen pots, with excellent smell and taste; fertile soil, pleasant surroundings).
The entrance should be facing East or North direction. The house should be built
with wood of one of the following plants: Bilva, Tinduka, Indugi, Bhallataka,
Varuna, Khadira or any other wood which is advised by Brahmana or a person who
possesses knowledge of Atharva Veda.

The house should be furnished with curtains, linen, bed spread, and smeared with
cow dung or lime. A separate corner is allotted for the fireplace, water, mortar and
pestle, and separate rooms for bathroom and kitchen. They should be constructed
according to Vastu Shastra and in such a way that it is convenient in all seasons.

 Sangrahaniya Dravyani:
Sangrahaniya Dravyani are the articles which are supposed to be stored in or
should be kept near Sutikagara for the process of Prasava.

- Ghrita, Taila, Madhu, Saindhava, Sauvarchala, Kala, Vida Lavana, Vidanga, Kustha,
Devadaru, Nagara, Pippali, Pippalimoola, Hastipippali, Mandukaparni, Ela, Langali,
Vacha, Chavya, Chitraka, Chiru-Bilva, Hingu, Sarshapa, Lashuna, Kataka,
Kanakanika, Nipa, Atasi, Balvaka, Bhurjapatra, Kulattha, etc.
- Maireya, Sura, Asava, etc.
- Two pieces of stones, pestle & mortars, two needles made of gold and silver,
Ardhadhara Shastra, Kshauma sutra, two bed made of Bilva, wood of Tinduka and
Ingudi for lighting fire.
- Donkey, bull, cow
- Good-hearted multiparous women who are responsible, strong in character,
experienced, charming, affectionate, free from grief, stress, and who can cheer up
the woman in labour.
- Old ladies and Brahmanas possessing knowledge of Atharva Veda should also be
present.
 Wondershare
PDFelement

Sangrahinya Guna & Karma

Dravyani
Madhu & Administered to newborns, sometimes with Svarna -> Suvarnaprashan. It triggers
Ghrita immunological mechanism in neonates.
Taila Excellent Vatahara Dravya, used for Abhyanga & Parisheka or emergencies where Vata
has obstructed/delayed process of Prasava.
Saindhava Sukshma guna; excellent penetrability, used along with Ghrita to clean Ulba or
Lavana administered with Ghrita for Garbhodaka Vamana if required.
Kustha Antiseptic, antibacterial, disinfectant, Kustha taila is applied on umbilical cord stump
after Nabhinadi Chedana.
Devadaru Antibacterial, anti-inflammatory, Garbhashaya & Stanyashodhana
Nagara / Supports involution of uterus, antispasmodic, Stanyashodhana
Shunthi
Pippali, Antibacterial, analgesic, carminative, facilitates expulsion of lochia
Pippalimoola, (Lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue.
Hastipippali Lochia discharge typically continues for four to six weeks after childbirth,
Throughout the postpartum period or puerperium.)
Mandukaparni Stanyajanana, Stanyashodhana, antispasmodic, analgesic
Langali Garbhashaya sankochaka
Vacha Garbhashaya sankochaka, given with Pippalimoola in case of difficult labour
Chitraka Garbhashaya sankochaka, expulsion of uterine contents, effective in Makkalla Shula
Chiru-Bilva Vatanulomana, useful in obstructive labour
Chavya Supports involution of uterus and expulsion of lochia
Hingu Antispasmodic, sedative, Garbhashaya shodhana, Vatanulomana
Sarshapa Garbhashaya sankochaka, useful in Aparasanga
Lashuna Vatahara, antimicrobial, antiseptic, antispasmodic
Atasi Vatahara, anti-inflammatory, effective in oedema
Bhurjapatra Haemostatic, effective in convulsions, hysteria, seizure disorders
Kulattha Garbhashaya sankochaka, facilitates expulsion
Sura, Asava, Used as anesthetic agent, sedative for relief of post-operative pain
etc.
Two stones Stimulation of auditory reflexes for Prana-pratyagamana
Ardhadhara Nabhinadi Chedana
Shastra
Kshauma Ligating the umbilical cord before Nabhinadi Chedana
Sutra
Needles Suturing
Bed made Smooth surface, anti-fungal property
from Bilva
Tinduka & Used as firewood for fumigation to keep away insects, antibacterial, provides warmth
Ingudi wood and constant temperature
Mid-wives Assistant to the physician, to care for the patient
Brahmana Spirituality, religion, emotional & psychological support
Cow Symbol of dignity, strength, maternity, selfless service. Supply of fresh cow milk as best
nutrient for mother and newborn if colostrum is not given.
 Wondershare
PDFelement

 Sutikagara Pravesha vidhi: (Entry and Stay in Sutikagriha)

After 9th month, on predetermined auspicious day when the moon is high and all
stars or planets are favourable, then in Maitra Muhurta (around 7:30-8:30) after
Shanti Homa (oblation) the pregnant woman should enter the Sutikagriha
followed by cow, Brahmana, Agni and Jala.

The cow should be fed with grass, water, honey, and Laja by the Garbhini, then
she must wash the hands and feet of Brahmana and offer him rice, flowers, fruits
and salutations.

After washing her hand and feet, she should drink water, seek blessings by reciting
holy hymns and enter the Prasava-alaya with her right foot first, and stay there
until onset of labour.

If there is even slight Vibandha or Sanga of Pureesha and Mutra, Phala varti should
be administered. Apana Vayu must not be vitiated at the time of labour as it can
cause Udavarta and Garbha & Garbhini will be both in danger.

Apathya during Prasava Kala:

Shrama, Nasya, Raktamokshana, Vishama ahara, Viruddha ahara, Asatmya Ahara,
Adhyashana, Vega sandharana, Divasvapna, Abhishyandi, Guru and Vistambhi
Dravya
 Wondershare
PDFelement

Prasava-Avastha

1) Prajayini / Prasava-Utsuka (1 or 2 days before 1st stage of labour)

2) Asanna Prasava (1st stage of labour)

3) Upasthita Prasava (End of 1st stage and beginning of 2nd stage of labour)
4) Parivartita Garbha (2nd stage of labour)
5) Apara Patana (3rd stage of labour)

1) Prajayini / Prasava-Utsuka (1 or 2 days before 1st stage of labour)

 This stage is mentioned by Acharya Sushruta & Acharya Bhavamishra.
 Lakshana: Looseness of abdomen, release of bond of Hridaya, pain in the thighs.

2) Asanna Prasava (1st stage of labour)

 The woman is about to delivery; delivery is impending.
 Lakshana: Exhaustion, fatigue, droops eyelids, release of chest compression (due
to reduction of fundal height), uterus descends, lower abdominal heaviness, pain
in groin, bladder, sacrum, hips, flanks & back, vaginal discharge (Yonisrava), loss of
appetite, labour pains (Avi & Grahishula) with discharge of liquor (Garbhodaka).

3) Upasthita Prasava (End of 1st stage and beginning of 2nd stage of labour)
 This stage is mentioned by Acharya Sushruta & Acharya Arundatta.
 Lakshana: Garbha is turning with its head towards Yoni, pain in back, sacral region,
around the hip region, defecation & micturition (due to compression of rectum &
bladder by descending uterus) and mucosal vaginal discharge.

4) Parivartita Garbha (2nd stage of labour)

 In this stage the foetus will be delivered.
 Lakshana: Garbha further descends from Hridaya pradesha into Udara pradesha,
at the region of Basti. Avi (uterine contractions) are very strong & frequent, there
is severe compression and tearing pain in the vagina. The foetus will be expelled
very soon.

5) Apara Patana (3rd stage of labour)

 In this stage there is expulsion of Apara (placenta).
 The delivery of foetus in vertex presentation followed by expulsion of placenta is
normalcy, all other conditions are abnormal.
 After delivery of foetus, one of the attendants must inspect carefully whether
placenta is expelled or not.
 Wondershare
PDFelement

 Avi
Normally, during onset of labour there is presence of Avi, dilatation of Aparamukha along
with Grahishula.
Avi is considered as normal uterine contractions and Grahi as abdominal muscle
contractions.
A woman is ready to deliver the foetus when following criteria are fulfilled:
i) Normal situation of Garbha (foetus)
ii) Dilatation of Aparamukha (cervix uteri)
iii) Presence of Avi (normal uterine contractions during labour i.e. contraction, relaxation
& retraction) along with Grahishula (seizing like pain arising due to contraction of
abdominal wall). Even if there is severe Grahishula, the woman does not get an early
delivery without presence of Avi.
Mithya-avi: If Avi is delayed, the foetus and mother get distressed. Weak uterine
contractions can delay the labour which may lead to asphyxia of the foetus.

 Prasava Paricharya
 Asanna Prasava Paricharya: (Management of 1st stage of labour)
After Taila Abhyanga and Ushnodaka Snana, the woman who is about to deliver
should be given Yavagu to her full capacity.
With the onset of labour pain, the woman is made to sit or lie down on a soft bed.
She must be surrounded by mid-wives who are responsible, strong in character,
experienced, charming, affectionate, free from grief, stress, and who can cheer up
the woman in labour.

 Garbha-Anavatarane Chikitsa: (Treatment in case the foetus fails to descend)

If there is no progress in spite of Avi, the patient is asked to get up, walk and yawn.
She should be frequently administered Churna of Kustha, Langali, Vacha, Chitraka,
Chiru-Bilva & Chavya through the nose.
Dhumapana with Bhurjapatra, Shimshipa Niryasa or Sarjarasa can also be done,
followed by kneading or gentle massage of waist, flanks, back & thighs with
lukewarm oil. All these procedures enable the descent of the foetus and ensures
rapid progress of labour.

 Pravahana: (Bear down)

Pravahana = Bear down = Exert downwards pressure to push the baby out.)
An experienced midwife must instruct the Garbhini not to bear down if there is
absence of labour pain (uterine contractions) because this will only exhaust her
without any progress in labour. Moreover, it is liable to cause Vikriti (congenital
abnormalities) and the child may suffer from Shvasa, Kasa, Shosha, Pleeharoga.
Just like sneezing, yawning, flatus, urine or faeces are expelled easily in the
presence of urge, it would take a lot of effort to expel them when the natural urge
is absence, and it may also lead to vitiation of Vayu and cause various disorders; in
the same way, if Avi (uterine contractions) are not present, only Pravahana is
contraindicated.
 Wondershare
PDFelement

 Garbhavataranantara Karma: (Management after descend of the foetus)

After the descent of Garbha, the woman is advised to lie on the bed and bear
down when Avi are present.
One of the attendants should recite the following mantra:
“Prithvi, Jala, Akasha, Teha, Vayu, Vishnu and Prajapati should protect you and
relieve you from this Shalya (foetus). Oh! May you deliver without any hindrance,
free from any trouble. May Lord Karthikeya protect you and may you give birth to
a son who resembles him.”

 Apara Patana & Apara Sanga: (Expulsion of placenta)

▪ स्वाभाविक अपरा पातन (Normal expulsion of placenta)
- The delivery of foetus in vertex presentation followed by expulsion of placenta is
normalcy, all other conditions are abnormal.
- After delivery of foetus, one of the attendants must inspect carefully whether
placenta is expelled or not.

▪ अपरासङ्ग उपद्रि (Complications of placental retention)

- Retained placenta obstructs the passage of Vata, Vit & Mutra.
- It may lead to Anaha, Adhmana, Udarashoola, Aruchi.

▪ अपरासङ्ग विवकत्सा (Treatment for retention of placenta)

Placental retention is due to vitiation of Vata Dosha. Therefore, the treatment
should cause Vatanulomana.
The following treatment methods should be applied in successive order if placenta
does not get expelled.

1) बह्य उपचार (External manipulations)

a) Forceful compression of the abdomen over the umbilicus.
b) Repeated striking or compressing of the pelvis with heels.
c) Forceful compression by holding the woman by the hip.
d) Internal throat and palate should be touched with braid of hair or a finger
wrapped with hair.
e) After oleating the vagina and compressing her flanks, the woman should
be given forceful jerks or the uterus should be compressed.
 Wondershare
PDFelement

2) बह्य औषति प्रयोग & स्थातनक तचतकत्सा

(External use of medicine & local treatments)
a) Yoni Dhupana: ▪ Bhurjapatra & Guggulu
b) Yoni Lepana or Purana: ▪ Kalka prepared from Guda & Shunthi
c) Anga Lepana: ▪ Langali Kalka should be applied over palms and
abdomen or palms and soles.
d) Pichu Dharana: ▪ Pichu should be soaked in oil prepared with
Shatapuspa, Kustha, Madanaphala & Hingu and
placed in vagina.
e) Yoni Prakshalana: ▪ Sarshapa Taila processed with Shatahva,
Sarshapa, Ajaji, Shigru, Tikshnaka, Chitraka,
Hingu, Kustha & Madanaphala along with
Godugdha & Gomutra

3) बस्ति प्रयोग (Use of Basti)

a) Anuvasana Basti: ▪ Shatapuspadi Taila
▪ Sarshapa Taila with Kalka prepared from Shigru,
Sumukha, Maricha, Ajaji, Chitraka along with
Godugdha & Gomutra

b) Asthapana Basti: ▪ Kalka of Shatapuspa, Vacha, Kushta, Kana &

Sarshapa with Sneha Dravya & Saindhava Lavana
▪ Suramanda mixed with Churna of Siddharthaka,
Kustha, Langali and Mahavriksha Ksheera

c) Uttara Basti: ▪ Taila processed with Siddharthaka, Kustha,

Langali & Mahavriksha Ksheera

4) आभ्यन्तर औषति प्रयोग (Internal use of medicine)

a) Kalka prepared from Guda & Shunthi.
b) Kalka prepared from Kushta & Langali is to be taken with Madya.
c) Kalka prepared from Kustha & Ela is to be taken with Madya.
d) Kvatha prepared from Shveta & Rakta Arka is to be taken with Madya.

5) अपरा का हि तनष्काशन (Manual removal of placenta)

- When all previous described methods or drugs are not successful in expulsion
of placenta, then manual removal of placenta should be done.
- Lubricated hand with trimmed nails should be inserted following the
umbilical cord & placenta is extracted.
 Wondershare
PDFelement

 Navajata Shishu Paricharya

Neonatal care can be divided into the following to aspects:

1) जािमात्रा पररचयभ = प्राण प्रत्यागमन, उल्ब पररमाजभन, गर्ोदक वमन, नातर्नाल छे दन

2) सध्योजाि पररचयभ = िै ल पररषेक, स्नान, तपचु िारण, उदक कुम्भ स्थापन, प्राशन
+
3) िन्यपान, रक्षाकमभ

1) जातमात्रा पररिर्य
It includes all the methods that are to be adopted immediately after birth until the
cutting of umbilical cord.

 प्राण प्रत्यागमन
Prana Pratyagamana literally refers to bringing back the life / air.
During the phase of transition from dependency to independency, the
establishment of respiration in babies is an important part. Most of the babies
pass this period of transition easily, only in some cases, assistance in various
stages is required.
The process of assisting in these cases is known as प्राण प्रत्यागमन.

Indications for प्राण प्रत्यागमन:

There are no direct references regarding the indication of प्राण प्रत्यागमन. However,
the reasons mentioned for inability of the foetus to cry may lead to difficulty in
breathing as well.

- Obstruction of oral cavity with Jarayu (mucous and foetal membranes).

- Throat is coated with Kapha (amniotic fluid).
- Obstruction of Vayumarga (respiratory tract).
- Kleshitha (Stress and strain after delivery)

Steps of प्राण प्रत्यागमन:

1) अश्मनो संघट्टनम
2) मु ख पररषेक
3) वायु
 Wondershare
PDFelement

1) अश्मनो संघट्टनम
- Striking of stones near the ears for auditory stimulation to activate
respiratory centres of the brain.
- Ears are the most developed sensory organ in a newborn child. The sound
waves produced by striking of stones near the ears travel down the
vestibulocochlear nerve, through intermediate stations such as cochlear
nuclei and superior olivary complex situated in the brainstem. The respiratory
centres are situated at the brainstem as well.
The brainstem controls several important functions such as alertness, arousal,
breathing, blood pressure, heart rate, digestion, etc.
Hence, by auditory stimulus, there will be simultaneous activation of other
centres present in the brainstem, including the respiratory centre which
results in support of breathing.

2) मु ख पररषेक
- Sprinkling of cold and hot water alternatively over the face.
- When water is sprinkled, there is immediate cutaneous stimulation which in
turn stimulates the autonomic nervous system and triggers the blood
pressure by sudden vasoconstriction of the peripheral vessel.
Sudden hot stimulation to the face or gentle slaps on the cheeks stimulate the
trigeminal system which is close to the midbrain, as well as the vagal nuclei in
the medulla to stimulate the blood pressure and circulation in the brain is
restored which in turn promotes the respiratory centres of the brainstem.

3) वायु
- Fanning with blackened winnowing basket made up of reeds of Ishika, Nala,
Munja, Vamsha, etc.
- It enhances the amount of oxygen saturation in the atmosphere which helps
improving the air supply and in regaining the consciousness of the child.

 उल्ब पररमाजयन
- Ulba = vernix caseosa
- Ulba parimarjana is the cleaning of Ulba.
- Ulba is the membrane that covers the embryo.
- According to A. Sushruta, the infant’s Ulba and Mukha should be cleaned by
Saindhava Lavana & Sarpi.
 Wondershare
PDFelement

 गभोदक िमन
- Garbhodaka = Amniotic fluid
- In certain instances, the baby may suck or aspirate Garbhodaka. In such cases,
the baby is made to vomit the fluid. This method is known as Garbhodaka vamana.
- It is done by administering Saindhava Lavana with Sarpi to the baby to induce
vomiting.

 नावभनाल छे दन / नावभकतय न
Nabhinala Chedana is the process of cutting the umbilical cord.

- Required materials: अिभ िार शस्त्र, कापभस सूत्र, कुष्ठ िै ल, लोध्र मिु क तप्रयङ्गु

- Procedure: (According to A. Charaka)

Umbilical cord should be tied with Karpasa sutra at the distance of 8 angula from
naval side. Then it is cut just above the knot with Ardhadhara Shastra.
The stump has to be smeared with Kusta taila & remaining Dravya to prevent
infections and promote healing.

- Complications of improper Nabhinala Chedana:

आयाम Elongation of umbilical cord

व्यायाम् Enlargement of umbilicus

उत्तु स्तिका Elongation & Enlargement

तपस्तितलका Herniation

तवनातमका Inflammation / Depression of umbilicus

तवजृस्तिका Pulsetile swelling at umbilical region

नातर्पाक Due to vitiation of Doshas in Nabhi, ther will be foul smell, watery
discharge, pain & swelling.
Chikitsa = Abhyanga with Taila, Lepana with Durva + Bala

नातर्िु स्ति Vitiated Vata causes enlargement of umbilicus, causing pain.

Chikitsa = Snehana, Bala hapushadi Kvatha

प्रर्ातलका Umbilicus becomes enlarged and elongated in the shape of musha.

Chikitsa = Snehana, Bala hapushadi Kvatha
 Wondershare
PDFelement

2) सध्योजात पररिर्य
It includes the methods that are to be adopted up to 24 hours after delivery.

 तै ल पररषेक
- It is the process of oleating the child.
- Due to the stress during delivery, Vata Dosha will be aggravated in the child,
so Taila parisheka should be done with Bala taila.

 स्नान
- It is the process of bathing the child.
- Snana should be performed with Ksheeravriksha Kashaya + Svarna-
Gandhodaka.

 वपिु धारण
Taila pichu is applied on the head of the child.

 उदक कुम्भ स्थापन

A pot with water purified by mantras should be kept next to the mother.

 प्राशन
Suvarnaprashana should be given to the child to activate the immune system
and provide strength. (Refer to Chapter XIII)

3) स्तन्यपान, रक्षाकमय
 स्तन्यपान
- According to A. Charaka, Stanyapana has to be started from first day.
It should be done from the right breast first.
- According to A. Sushruta & Vagbhata, Stanyapana should be started on the
4th day.

 रक्षाकमय / रक्षोघ्न कमय / रक्षोघ्न धू पन

Rakshakarma are protective measures which are adopted to protect the child
and mother from infectious organisms.
According to A. Sushruta, the following steps should be followed:
- The child should be covered with a silk cloth and made to sleep on a
comfortable bed which is covered with silk bed sheet.
- The child should be kept in a comfortable temperature. Fanning should be
done with branches of Pilu, Nimba, Badara or Parushaka.
- Taila Pichu Dharana on the child’s head.
- Fumigation with Vacha, Sarshapa, Kusta, Hingu, Atasi, Rasona, etc.
- Same drugs can be used to tie a Pottali and place around the neck, hands &
legs of the child.
- The floor should be sprinkled with power of Tila, Sarshapa & Atasi.
- A constant fire should be lit in the room until Namakarana Samskara.
 Wondershare
PDFelement

Normal labour / Eutocia

Labour is a series of events that take place in the genital organs in an effort to expel the
viable products of conception out of the wmb through the vagina into the outer world.
Delivery is the actual birth of the foetus.
A labour is defined as normal when it is a vertex presentation, starts spontaneously at term
and terminates naturally without any artificial aid and complications.

Cause of Onset of Labour:

The exact cause and mechanism for onset of labour is unknown. The following factors play a
significant role:
1) Hormones: Progesterone, Oestrogen, Oxytocin, Prostaglandins
2) Foetus and placenta: Increased cortisol production from foetal adrenal gland may
influence onset of labour by stimulating oestrogen production from the placenta.
3) Mechanical factors:
a) Uterine distension -> Like any hollow organ in the body, when the uterus in
distended to a certain limit, it starts to contract to evacuate its contents. This explains
the preterm labour in case of multiple pregnancy and polyhydramnios.
b) Stretch of the lower uterine segment by the presenting part near term.

Uterine Activity in Labour:

Uterus contracts irregularly throughout the pregnancy. These contractions are painless and
have no effect on dilatation of cervix. They are known as Braxton Hicks contractions.
-> True Labour Pains:
- The contractions become regular, are painful, begin gradurally, work up to a
maximum, then die away. Each contraction lasts for 30-45 seconds.
- The uterus hardens with change in abdominal contour.
- Uterine contractions are increased in intensity and frequency by purgatives, enema,
stretchting of cervix, pressure on pelvic floor by the presenting part and
administration of oxytocin and prostaglandins.
- In early labour, contractions occur every 10-20 minutes. The interval gradually
shortens and by the end of 1st stage, there are contractions every 2-3 minutes.
- In between contractions, the uters relaxes. During that phase, placental circulation
is re-established as it almost ceases during contractions.
- If uterine contractions are continuous or precipitated, it leads to placental
circulatory embarrassment, foetal hypoxia and foetal distress.
True Labour Pains False Labour Pains
Pain at regular intervals Irregular
Intervals gradually shorten No change
Duration and severity increases No change
Pain starts in the back and moves to the front Pain is localized in front and lower abdomen
Walking increases the intensity No change
Uterus hardens and abdominal contour changes No relationship
Show is present No show
Cervix effaced and dilated No change in cervix
Descent of the presenting part No descent
Sedation does not stop true labour Efficient sedative stops false labour pains
Fomation of bag of waters No formation
 Wondershare
PDFelement

Normal Mechanism of Labour

During the course of labour, the series of changes or adaptation in position and attitude the
presenting part has to make so as to pass through the birth canal is known as mechanism of
labour.
The presentation of 95% of all labours is occiput / vertex.

 Criteria for Normal Mechansim of Labour:

Lie is longitudinal, Presentation cephalic, Position ROA or LOA, Attitude is good
flexion, Denominator is occiput, Presenting part is posterior part of anterior
parietal bone

 8 Cardinal Movements = EDFIEREE

1) Engagement
2) Descent
3) Flexion
4) Internal rotation
5) Extension
6) Restitution
7) External rotation
8) Expulsion

Crowning is often referred to as the “ring of fire” in the birthing process. It is when the
baby's head becomes visible in the birth canal due to full dilatation of cervix during
extension.

Onset of Labour
It is characterised by:
- True labour pain.
- The show: It is an expelled cervical mucus plug tinged with blood from ruptured small
vessels as a result of separation of the membranes from the lower uterine segment. Labour
usually starts several hours to few days after show.
- Dilatation of the cervix: A closed cervix is a reliable sign that labour has not begun. In
multigravidae the cervix may admit the tip of the finger before onset of labour.
- Formation of the bag of fore-waters: It bulges through the cervix and becomes tense during
uterine contractions.
 Wondershare
PDFelement

Stages of Labour

1) First stage
It is the stage of cervical dilatation.
Starts with the onset of true labour pain and ends with full dilatation of the cervix i.e. 10 cm
in diameter.
It takes about 10-14 hours in primigravida and about 6-8 hours in multipara.

2) Second stage
It is the stage of expulsion of the foetus.
Begins with full cervical dilatation and ends with the delivery of the foetus.
Its duration is about 1 hour in primigravida and ½ hour in multipara.

3) Third stage
It is the stage of expulsion of the placenta and membranes.
Begins after delivery of the foetus and ends with expulsion of the placenta and membranes.
Its duration is about 10-20 minutes in both primi and multipara.

4) Fourth stage
It is the stage of early recovery.
Begins immediately after expulsion of the placenta and membranes and lasts for one hour.
During which careful observation for the patient, particularly for signs of postpartum
haemorrhage is essential. Routine uterine massage is usually done every 15 minutes during
this period.

1) First Stage
Causes of cervical dilatation:
- Contraction and retraction of uterine musculature.
- Mechanical pressure by the forebag of waters, if membranes still intact, or the presenting
part, if they had ruptured. This in turn will release more prostaglandins which stimulate
uterine contractions and cervical effacement.
- Softness of the cervix which has occurred during pregnancy facilitates dilatation and
effacement of the cervix.

Mechanism of cervical dilatation:

In primigravidas, the cervical canal dilates from above downwards i.e. from the internal os
downwards to the external os. So its length shorts gradually from more than 2 cm to a thin
rim of few millimetres continuous with the lower uterine segment. This process is called
effacement and expressed in percentage so when we say effacement is 70% it means that
70% of the cervical canal has been taken up.
Dilatation of the cervix (external os) starts after complete effacement of the cervix.
In multigravidas, effacement and dilatation occur simultaneously.
In normal presentation and position, the head is applied well to the lower uterine segment
dividing the amniotic sac by the girdle of contact into a hindwaters above it containing the
foetus and a forewaters below it. This reduces the pressure in the forewaters preventing
early rupture of membranes. After full dilatation of the cervix the hind and forewaters
become one sac with increased pressure in the bag of forewaters leading to its rupture.
 Wondershare
PDFelement

Phases of cervical dilatation:

i) Latent phase: This is the first 3 cm of cervical dilatation which is slow and takes
about 8 hours in nulliparae and 4 hours in multiparae. Pain, frequency, intensity,
duration and efficiency of contractions gradual increase. This phase may be
shortened by artificial rupture of membranes or oxytocin infusion if indicated.

ii) Active phase: It has 3 components -> a) Acceleration phase

b) Maximum slope
c) Deceleration phase
The phase of maximum slope is the most detectable and the two other phases are of shorter
duration and can be detected only by frequent vaginal examination.
The normal rate of cervical dilatation in active phase is 1.2 cm/ hour in primigravidae and 1.5
cm/hour in multiparae. If the rate is < 1cm / hour it is considered prolonged.
Pain is distressing and contractions become more frequent; every 3-5 minutes lasting 60-90
seconds with increased intensity. The membranes usually rupture spontaneously at the end
of this stage. Steady foetal descent begins.

2) Second Stage
i) Descent:
It is continuous throughout labour particularly during the second stage and caused by:
Uterine contractions and retractions. The auxiliary forces which is bearing down brought by
contraction of the diaphragm and abdominal muscles.
The unfolding of the foetus i.e. straightening of its body due to contractions of the circular
muscles of the uterus.

ii) Engagement:
The head normally engages in the oblique or transverse diameter of the inlet.

iii) Flexion:
As the atlanto-occipital joint is nearer to the occiput than the sinciput, increased flexion of
the head occurs when it meets the pelvic floor according to the lever theory.
Increased flexion results in:
- The suboccipito-bregmatic diameter (9.5 cm) passes through the birth canal instead of the
suboccipito-frontal diameter (10 cm).
- The part of the foetal head applied to the maternal passages is like a ball with equal
longitudinal and transverse diameters as the suboccipito-bregmatic = biparietal = 9.5 cm.
The circumference of this ball is 30 cm.
- The occiput will meet the pelvic floor.

iv) Internal rotation:

The rule is that the part of foetus meets the pelvic floor first will rotate anteriorly. So that its
movement is in the direction of levator ani muscles (the main muscle of the pelvic floor) i.e.
downwards, forwards and inwards.
In normal labour, the occiput which meets the pelvic floor first rotates anteriorly 1/8 circle.
 Wondershare
PDFelement

v) Extension:
The suboccipital region lies under the symphysis then by head extension the vertex,
forehead and face come out successively.
The head is acted upon by 2 forces:
a) The uterine contractions acting downwards and forwards.
b) The pelvic floor resistance acting upwards and forwards so the net result is
forward direction i.e. extension of the head. Crowning occurs.

vi) Restitution:
After delivery, the head rotates 1/8 of a circle in the opposite direction of internal rotation
to undo the twist produced by it.

vii) External rotation:

The shoulders enter the pelvis in the opposite oblique diameter to that previously passed by
the head. When the anterior shoulder meets the pelvic floor it rotates anteriorly 1/8 of a
circle. This movement is transmitted to the head so it rotates 1/8 of a circle in the same
direction of restitution.

viii) Expulsion: The anterior shoulder hinges below the symphysis pubis and with continuous
descent the posterior shoulder is delivered first by lateral flexion of the spines followed by
anterior shoulder then the body.

3) Third Stage
After delivery of the foetus, the uterus continues to contract and retract. As the placenta is
inelastic, it starts to separate through the spongiosa layer by one of the following
mechanisms:
a) Schultze’s mechanism (80%)
The central area of the placenta separates first and placenta is delivered like an inverted
umbrella so the foetal surface appears first followed by the membranes containing small
retroplacental clot. There is less blood loss and less liability for retention of fragments.
b) Duncan’s mechanism (20%)
The lower edge of the placenta separates first and placenta is delivered side ways.
There is more liability of bleeding and retained fragments.

The 3rd stage is composed of 3 phases:

i) Placental separation
ii) Placental descent
iii) Placental expulsion
Placental expulsion usually occurs within 10-20 minutes after delivery of the baby. If
placenta does not get expulsed after 30 minutes, it is considered as retained placenta and it
might has to be removed manually.

4) Fourth Stage (Golden Hour)

It is the stage of early recovery.
Begins immediately after expulsion of the placenta and membranes and lasts for one hour.
During which careful observation for the patient, particularly for signs of postpartum
haemorrhage is essential. Routine uterine massage is usually done every 15 minutes during
this period.
 Wondershare
PDFelement

Management of Labour

1) Management of First stage

- When labour is established, constant supervision is vital.
- Walking during labour intensifies uterine contractions, hence she should be free to walk.
The mother should be discouraged to lie straight on her back to avoid venecaval
compression.
- Oral fluids are permitted but solids are better avoided.
- Patien should be encouraged to pass urine every 2 hours; catherzitation if necessary.
- Traditionally, soap and water enema is given to enhance uterine contractions and prevent
soiling of perineum in second stage preventing faecal contamination.
- BP is checked every 2 hours, PR and FHR are checked every 30 minutes, temperature every
4 hours.
- Maternal distress usually occurs due to neglected prolonged labour.
- Amniotomy may be done to induce and augment labour.
- The labour process is to be charted on a partogram.
- During the first stage, the labour progresses faster and the patient feels less pain if she
breathes slowly and deeply during each uterine contraction. She should avoid bearing down.
The more effective the relaxation, the more rapid the cervical dilatation.
Bearing down during first stage of labour leads to:
a) Delay in cervical dilatation.
b) Needless loss of strength.
c) It forces the uterus down and stretches the supporting ligaments predisposing
prolapse.

2) Management of Second stage

Bearing down efforts of a patient signals towards onset of second stage. P/V examination to
confirm full dilatation, position, station of head and exclude cord prolapse.

Clinical indicator of commencement of second stage:

- Increase in blood flow.
- Patient wanting to bear down with each contraction.
- Patient wants to defecate due to pressure on rectum.
- Nausea and retching occur as cervix reaches full dilatation.

General management:
- The patient must not be left alone and is confined to the bed.
- Nil by oral except sips of water.
- FHR is checked every 5-10 minutes.
- Patient is transferred to labour table when bearing down effort is pronounced and there is
gaping of anus.
- IV infusions may be necessary, especially when the woman cannot take water orally due to
nausea, vomiting thus preventing dehydration.
- Analgesics may be given, pitocin in case of ineffective uterine contractions.
 Wondershare
PDFelement

Position for delivery:

- Generally dorsal position with thighs flexed or in lithotomy position.
- Semi-recumbent position is also favoured as it is convenient for mother since delivery is
aided by gravity, but warrants a birthing chair and suitable bed for easy access to the
perineum.

Bearing down:
The patient must bear down during contractions but if there is rapid emergence of foetal
head, it can be slowed down by rapid panting through the open mouth during contraction.
While breathing in and out rapidly, the diaphragm moves making it impossible for intra-
abdominal pressure to build up, hence power to bear down is lost.

Ritgen manoeuvre:
It is done to encourage extension of foetal head to hurry the delivery process.
Criteria for this manoeuvre is that it is performed between uterine contractions and the
occiput should be under symphysis.
The obstetrician’s hand covered with towel or pad is placed over the maternal anus.
Extension of foetal head is helped by pressing with the other hand against the face
(preferably chin).

Once the head is delivered:

- Head is supported as it restitues and rotates externally. The face is wiped and mucus
aspirated from motuh and throat.
- Rule out cord around the neck. If it is present, it may be slipped over the head. If it is coiled
tightly, it must be clamped, cut and unwound.

Delivery of shoulder and trunk:

- Movement of restitution and external rotation takes place andit is advisable to wait for the
next uterine contractions to deliver the anterior shoulder by depressing the head towards
the rectum. Finally, guiding the head upward towards mother’s abdomen allowing posterior
shoulder delivery off the perineum.
- The trunk is delivered by lateral flexion while supporting the shoulder with the right hand
and buttock with the left hand.
- IV ergometrine is administered with delivery of anterior shoulder.
- It is important to remember that the obstetrician merely lowers and lifts the baby’s head to
facilitate birth of shoulder and does not exert traction as it may damage the nerve plexus in
the neck. The forces that actually pushes out the shoulders are bearing down efforts or by
pressure on fundus by an assistant.

Clamping of the cord:

Umbilical cord is clamped approximately 5 cm away from foetal abdomen and second clamp
is placed as close to the vulval outlet as possible so that it helps appreciation of extra
lengthening of the cord during the third stage and prevents the possibility of haemorrhage
from cord in case of twins.

Neonatal care
 Wondershare
PDFelement

3) Management of Third stage

The third stage is a natural spontaneous process. It is supervised and not to be interfered
unless there is delay or bleeding occurs.
The most important factor in placental separation is strong uterine contraction and
retraction. Anything that will enhance this uterine action will accelerate separation and
expulsion and will control bleeding.

Signs of placental separation -> Gush of blood per vaginum, lengthening of umbilical cord,
rise of fundus in abdomen.
Expulsion of placenta -> The patient is asked to bear down while gentle traction is applied on
the umbilical cord (Modified Brandt Andrews method) or pressure is applied on the fundus
(Credes method) and placenta is expelled.

Ergometrine 0.5 mg IM at the shoulder causes prolonged contraction of uterus without

relaxation; hence it is very effective in controlling excessive bleeding during the third stage.
Bleeding > 500 ml is considered abnormal.

Oxytocin may also be given IM or IV, but it is not as effective as ergometrine and it carries a
small risk of placental retention due to upper segment contraction.

Complications during third stage:

- Postpartum haemorrhage
- Placental retention
- Morbid adherent placenta
- Invesion of uterus
- Amniotic fluid embolism
- Obstetric shock

4) Management of Fourth stage

The patient is kept in the labour ward for an hour under observation for any abnormal
vaginal bleeding.
Blood pressure and pulse rate are measured.
This stage is considered very vital and calls for close observation and vigilance.

The following should be confirmed before leaving the labour room:

a) Uterus is firm and contracted
b) Bleeding is controlled
c) Vital signs of mother are normal
d) Baby is breathing well, has been breast fed and APGAR is normal.
 Wondershare
PDFelement

-> APGAR:
Activity = Muscle tone/movement
Pulse = Pulse rate/heart beat
Grimace = Reflex response
Appearance = Colour
Respiration = Breathing rate

APGAR score determines the extent or degree to which intra-uterine hypoxia has affected
the foetal vitality.
7-10 = No depression
4-6 = Mild to moderate depression
0-3 = Severe depression

Signs 0 points 1 point 2 points

Muscle tone Limp Flexion of extremities Active motion
Heart rate Absent < 100 > 100
Reflex irritability No response Grimace Cough, sneeze
Colour Blue-white Body pink, blue extremities Completely pink
Respiratory rate Absent Slow, irregular Good, crying

 Partograph
Partograph is a composite graphical record of key data (maternal and foetal) during
labour, entered against time on a single sheet of paper.

Components of a partograph:
- Patient identification
- Time recorded at hourly interval. Zero time for spontaneous labour is the time of
admission in the labour ward and for induced labour is the time of induction.
- Foetal heart rate - recorded at every 30 minutes
- State of membranes and colour of liquor
- Cervical dilatation and descent of the head
- Uterine contractions
- Drugs and fluids
- Blood pressure (recorded in vertical line) at every 2 hours and pulse at every 30 minutes
- Oxytocin-concentration in the upper box and dose (m IU/min) in the lower box
- Urine analysis
- Temperature record

Advantages of a partograph:
- A single sheet of paper can provide details of necessary information at a glance.
- No need to record the laboor events repeatedly.
- It can predict deviation from normal progress of labor early. So, appropriate steps could
be taken in time.
- Introduction of partograph in the management of labour (WHO 1994) has reduced the
incidence of prolonged labour and caesarean section rate.
- There is improvement in maternal morbidity, perinatal morbidity and mortality.
 Wondershare
PDFelement

 Episiotomy
(Muladhara Chedana)
Episiotomy is a surgically planned incision on the perineum and the posterior vaginal wall
during the second stage of labour.

 Benefits:
- It reduces the duration of second stage of labour.
- It is a surgical incicion so it is easy to repair & healing is better.
- Soft tissue are not unduly stretched which otherwise may be damaged leading to
prolapse of vagina wall or deficient perinium in future life.
- It widens out the birth passage:
-> Any instuementation or manouever if required can be done comfortably.
-> Foetal head is saved from sudden compression during birth.

 Indications:
- Primigravida patients due to rigid perinium, routinely given in all primigravidae.
- Previous plastic surgery e.g. Third degree perineal tear repair
- Instrumental delivery – forceps/ventuose devliery
- Threatened laceration of perineum:
◦ Large foetal size
◦ Deflexed head
◦ Rigid perineum

- Foetal factors:
◦ Prematurity
◦ Postmaturity
◦ Multiple pregnancy
◦ Foetal distress
◦ Abnormal presentation

 Timing:
- Bulging thinned perineum during conter-action
- Just prior to crowning
- When 3-4 cm of head is visible is the ideal time.
- During forceps delivery, made after the application of blade.

 Types:
1) Mediolateral: The incision is made downwards and outwards from the
midpoint of the fourchette either to the right or to the left.
It is directed diagonally in a straight line which runs about 2.5 cm away from
the anus (midpoint between anus and ischial tuberosity).

2) Median: The incision commences from the center of the fourchette and
extends posteriorly along the midline for about 2.5 cm.
 Wondershare
PDFelement

3) Lateral: The incision starts from about 1 cm away from the center of the
fourchette and extends laterally. It has got many drawbacks including chance
of injury to the Bartholin’s duct. It is totally condemned.

4) J-shaped: The incision begins in the center of the fourchette and is directed
posteriorly along the midline for about 1.5 cm and then directed downwards
and outwards along 5 or 7 o’clock position to avoid the anal sphincter.
Apposition is not perfect and the repaired wound tends to be puckered.
It is not widely practiced.

 Complications:
1) Immediate: Excessive bleeding, Third-degree perineal tear, Vulval
haematoma
2) Late: Wound gap, Infection, Painful scar, Dyspareunia

 Post-operative Care:
1) Dressing: The wound is to be dressed each time following urination and
defecation to keep the area clean and dry.
The dressing is done by swabbing with cotton swabs soaked in antiseptic
solution (povidoneiodine) followed by application of antiseptic powder or
ointment (furacin or neosporin).

2) Comfort: To relieve pain in the area, MgSO4 compression or application of

infrared heat may be used.
Ice packs reduce swelling and pain also. Analgesic drugs (ibuprofen) may be
given when required.

3) Ambulance:
The patient is allowed to move out of the bed after 24 hours.
Prior to that, she is allowed to roll over on to her side or even to sit, but only
with thighs apposed.

4) Removal of Stitches:
When the wound is sutured by catgut or Dexon which will be absorbed, the
sutures do not need to be removed.
If non-absorbable material like silk or nylon is used, the stitches are to be
removed on the 6th day.
The number of stitches removed should be checked with the record of the
stitches given.
 Wondershare
PDFelement

 Care and Resuscitation of Newborn

A) Immediate care after delivery of the head:

- Clearing mucus by electrical/mechanical mucus sucker or by a sterile gauze wrapped
around a finger. It prevents mucus from blocking the airway.
- Cleaning of eyelids from medial to lateral side prevents infection from vaginal flora.
- In case there is cord around the neck, it is slipped over the head. If it is tight, it should
be ligated one inch apart and cut.

B) Immediate care after birth:

- Prevention of hypothermia:
The delivery should be conducted in a warm room. The fan and AC should be switched
off and windows should be shut. Immediately after receiving the newborn, the baby
should be dried thoroughly in a pre-warmed towel and wrapped in another dry and
warm cloth. The newborn shoul be given to the mother as soon as possible. This also
promotes bonding and initiates early breastfeeding.
Succeeding checks for warmth should be performed every 15 minutes by feeling the
newborn’s feet. Bath may be given after body temperature becomes stable (usually after
24 hours).

- Eye care:
The eyes of a newborn should be cleaned with a sterile gauze piece or with 1% silver
nitrate solution or 2.5% povidone-iodine solution or 1% tetracycline ointment.
The eyes are cleaned from medial to lateral canthus in order to prevent spread of
infection from one eye to other, if any is present.

- Presence of congenital malformation:

The newborn should be thoroughly screened from top to bottom and in midline to
detect any congenital malformation. Special concentration should be given to orifice
examination.
Common congenital malformations:
Single umbilical artery, Simian crease, Dysmorphic features, Excessive drooling of saliva,
Imperforated anus, Oesophageal atresia, Tracheo-oesophageal fistula

- Vitamin K administration:
Vitamin K is necessary to help in production of active prothrombin which are deficient in
newborns for the first 5-8 days of life because intestinal flora cannot absorb Vitamin K
sufficiently.
Vitamin K is injected into vastus lateralis muscle and may cause hyperbilirubinemia as an
adverse reaction.
 Wondershare
PDFelement

C) Essential post-natal care:

- The place of residence of baby and mother should be clean and free from direct
exposure to wind or breeze. The child should be covered well with a clean cotton cloth
and constant monitoring should be done by frequently touching the child’s body parts to
look for any signs of cold stress.

- The soiled cloth should be changed as early as possible in order to prevent discomfort
to the child. The baby should be placed on a comfortable bed with slight elevation of the
head.

- The child should be fed with breastmilk every 2 hours until demand feeds are
developed by the child. The baby should be made to burp after every feed by placing it
on the mother’s shoulder and mildly patting its back.

- The umbilicus and the stump should be inspected for bleeding at every 2-4 hours after
ligation. The cord should be kept clean and dry and observed for any discharge or sign of
infection until healing occurs.

- Bathing soon after birth is not recommended. It is usually done after 24 hours. Vigorous
attempts should not be made to remove vernix caseoa. The skin should also be inspected
for superficial infections.

- The eyes should be cleaned daily.

- Breast-feeding should be initiated within 1 hour after delivery. Success in breast-

feeding depends largely on the adjustments made during the first few days of life.
At feeding time, the infant should be dry and neither too cold nor too warm. The child
should be kept in a comfortable, semi-sitting position to prevent vomiting with
eructation. The mother, too, should be comfortable and completely at ease.
Signs of effective sucking:
Baby’s mouth is moist and pink, Baby is alert and moves actively, Baby has a vigorous cry,
Good skin turgor, Fontanelles are flat and soft, Baby looks relaxed and satisfied after
feeding, Mother’s breast feels softer and less full after feeding, Breast milk ejection
reflex, Mother’s nipple is elongated after breast-feeding, but not pinched, blanched or
damaged.

- Weight: Weight should be measured as soon as possible after delivery and checked
frequently. It is normal for a full term newborn to lose 10% of body weight by day 3-4.
The weight is regained by day 7-10.

- Immuization: BCG, OPV and Hepatitis B are given in a newborn as a routine. The
childhood immunization starts by 6-8 weeks.
 Wondershare
PDFelement

C) Resuscitation of the Newborn

It is mandatory for a person trained in neonatal resuscitation to be present for all
deliveries. The following conditions may require neonatal resuscitation:
Preterm delivery, Non-vaginal delivery, Multiple pregnancy, Foetal distress, Meconium
staining, Severe IGUR, APH, Foetal abnormalities

The basics of pediatric resuscitation are similar to that of an adult. The main difference
being respiratory stimulation is given more importance in pediatric resuscitation whereas
cardiac stimulation is given more importance in adults.

The T-ABC’s of pediatric resuscitation:

a) Temperature:
- Dry immediately
- Provide warmth
The newborn babies are wet after birth and heat loss is rapid. So, it is
of prime importance that the body temperature is maintained during
resuscitation.

b) Airway:
- Position
- Clear, if required
Ensure that the airway (oral cavity) is open and it should be cleared if
required, for which the baby may be placed on a flat surface with the
neck slightly extended.

c) Breathing:
- Stimulate
Assess whether the baby has started spontaneous breathing. If not,
stimulate the baby by rubbing its back and flicking the soles.

d) Circulation:
- Assess the heart rate
Assess the heart rate and colour of the baby to know the adequacy of
oxygenated blood circulation.

Bag & Mask Ventilation:

A self-inflating resuscitation ambu bag is used with mask attached to oxygen.
Indications: Apnoea, Heart rate < 100 bpm, Persistent central cyanosis
Chest expansion is a reliable visible sign of effective ventilation.

If there is no improvement, endotracheal intubation is advised.

 Wondershare
PDFelement

CHAPTER iI: prasava vyapad

 Yonisamvarana / Yonisamvritti
Yonisamvarana is the condition in which the vaginal introitus (opening) gets constricted
due to vitiation of Vayu by Vatakara Ahara, Vyavaya, Ratrijagarana, etc.

After constriction of vaginal introitus, Vayu moves upwards and constricts the cervix
uteri. It further vitiates the intra-uterine foetus leading to obstruction of its mouth and
respiration causing Mrita Garbha (IUFD).
The internally aggravated Vayu causes constriction of maternal chest leading to shallow
respiration and upward movement of Hridaya due to abdominal distension which
ultimately leads to maternal death.

This fatal disease is called Yonisamvarana. It can be correlated to cervical dystocia and
warrants caesarean section.

 Garbhasanga
Garbhasanga is foetal retention inside Garbhashaya which leads to delayed labour
(Vilambita Prasava).

 Nidana:
Garbhasanga occurs due to vitiation of Vayu which causes malposition of either
one of the following three factors:
1) Shira (Head)
2) Amsa (Shoulder)
3) Jaghana (Pelvis)

 Chikitsa:
- Yonidhupana with Madanaphala.
- Dharana: Langali mula should be tied on hasta & pada.
- Nabhi lepana: Kalka is prepared with Pippali, Vacha, Jala & Eranda Taila.
- Abhyantara Aushadha: Matulunga mula + Madhuka (churna/kalka) with Ghrita.
- Mantra Chikitsa, Water treated with Chyavana Mantra, Five unhusked grains of
rice should be washed, enchanted with Mantra and thrown on the Garbhini.
 Wondershare
PDFelement

 Aparasanga
स्वाभाविक अपरा पातन (Normal expulsion of placenta)
- The delivery of foetus in vertex presentation followed by expulsion of placenta is
normalcy, all other conditions are abnormal.
- After delivery of foetus, one of the attendants must inspect carefully whether placenta
is expelled or not.

 अपरा पातन न होने पर उपद्रि (Complications of placental retention)

- Retained placenta obstructs the passage of flatus, feaces & urine.
- It may lead to Anaha, Adhmana, Udarashoola, Aruchi.

 विवकत्सा (Treatment for retention of placenta)

Placental retention is due to vitiation of Vata Dosha. Therefore, the treatment
should cause Vata-anulomana.
The following treatment methods should be applied in successive order if placenta
does not get expelled.

1) बह्य उपचार (External manipulations)

a) Forceful compression of the abdomen over the umbilicus.
b) Repeated striking or compressing of the pelvis with heels.
c) Forceful compression by holding the woman by the hip.
d) Internal throat and palate should be touched with braid of hair or a finger
wrapped with hair.
e) After oleating the vagina and compressing her flanks, the woman should
be given forceful jerks or the uterus should be compressed.

2) बह्य औषति प्रयोग & स्थातनक तचतकत्सा

(External use of medicine & local treatments)
a) Yoni Dhupana: ▪ Bhurjapatra & Guggulu
b) Yoni Lepana or Purana: ▪ Kalka prepared from Guda & Shunthi
c) Anga Lepana: ▪ Langali Kalka should be applied over palms and
abdomen or palms and soles.
d) Pichu Dharana: ▪ Pichu should be soaked in oil prepared with
Shatapuspa, Kustha, Madanaphala & Hingu and
placed in vagina.
e) Yoni Prakshalana: ▪ Sarshapa Taila processed with Shatahva,
Sarshapa, Ajaji, Shigru, Tikshnaka, Chitraka,
Hingu, Kustha & Madanaphala along with
Godugdha & Gomutra
 Wondershare
PDFelement

3) बस्ति प्रयोग (Use of Basti)

a) Anuvasana Basti: ▪ Shatapuspadi Taila
▪ Sarshapa Taila with Kalka prepared from Shigru,
Sumukha, Maricha, Ajaji, Chitraka along with
Godugdha & Gomutra

b) Asthapana Basti: ▪ Kalka of Shatapuspa, Vacha, Kushta, Kana &

Sarshapa with Sneha Dravya & Saindhava Lavana
▪ Suramanda mixed with Churna of Siddharthaka,
Kustha, Langali and Mahavriksha Ksheera

c) Uttara Basti: ▪ Taila processed with Siddharthaka, Kustha,

Langali & Mahavriksha Ksheera

4) आभ्यन्तर औषति प्रयोग (Internal use of medicine)

a) Kalka prepared from Guda & Shunthi.
b) Kalka prepared from Kushta & Langali is to be taken with Madya.
c) Kalka prepared from Kustha & Ela is to be taken with Madya.
d) Kvatha prepared from Shveta & Rakta Arka is to be taken with Madya.

5) अपरा का हि तनष्काशन (Manual removal of placenta)

- When all previous described methods or drugs are not successful in expulsion
of placenta, then manual removal of placenta should be done.
- Lubricated hand with trimmed nails should be inserted following the
umbilical cord & placenta is extracted.
 Wondershare
PDFelement

 Mudhagarbha
 Paribhasha:
1) According to Acharya Sushruta: The foetus which is developed
descends/presents abnormally and is not expelled even after it has reached
the birth canal and is stupefied or swooned due to vitiated Apana Vayu, it is
known as Mudhagarbha.

2) Acharya Dalhana: When the fully developed foetus gets obstructed by

vitiated Apana Vayu, it is called Mudhagarbha.

 Nidana:
- Excessive coitus, riding, travelling, staggering walk, falling down, compression,
running, trauma, abnormal posture wile sleeping, sitting, uneven surface, fasting,
suppression of urges, use of dry, pungent, bitter diet, grief, excessive use of alkali
or cauterization, diarrhoea, emesis, purgation, swinging, indigestion,
abortifacients, etc.

- Etiology of Mudhagarbha can be classisifed into 3 sections:

1) Functional Abnormalities:
a) Apana Vaigunya
b) Viruddha Ahara & Vihara
c) Garbha Sanga
d) Vilambita Prasava
e) Daiva Yoga (idiopathic)

2) Abnormalities of Garbha:
a) Vivriddha
b) Asamyagata
c) Anekadhapratipanna (abnormal lie, position, presentation)

3) Abnormalities of Yonimarga:
a) Yonisamvarana
b) Bhaga Sankocha
c) Yonibhramsha
d) Asamyag and Apathya Patha (abnormalities of soft & bony pelvis)

 Samprapti:
The foetus getting detached from its bond, descends between liver, spleen and
bowels. In this process it hyperactivates the Kostha. Due to this irritation, Apana
Vayu is vitiated and moves in abnormal directions causing pain in Parshva, Basti,
Udara, Yoni, and Adhmana, Mutrasanga, etc. Various disease may occur followed
by Raktasrava. Mudhagarbha which cannot be delivered may die.
 Wondershare
PDFelement

 Lakshana:
- Shula in Parshva, Basti, Udara, Yoni
- Adhmana, Mutrasanga
- Raktasrava, Garbhapatana, Mritagarbha

 Gati Bheda: (A. Vagbhata)

Garbhasanga occurs due to vitiation of Vayu which causes malposition of either
one of the following three factors:
1) Urdhva gati -> Jaghana (Pelvis)
2) Tiryak gati -> Amsa (Shoulder)
3) Nyubja gati -> Shira (Head)

 Dosha Bheda & Lakshana: (A. Harita)

1) Vataja = Bastishoola, Yonidwar-avarodha, Jathargarjana, Adhmana,
Toda, Angabhanga, Nidrabhanga
2) Pittaja = Shoola, Tridoshaja Jvara, Trishna, Bhrama, Mutrakricchra,
Shiro-arti
3) Kaphaja = Alasya, Tandra, Nidra, Jadata, Adhmana, Vepathu, Kasa,
Virasata
4) Dvandvaja = VP/VK/PK lakshana
5) Sannipatika = VPK lakshana

 Bheda: (A. Sushruta)

A) Gross classification: - 4
1) Kilaka = Garbha obstructs Yonimukha like a Kilaka (wedge) with both
hands, feet and head upwards.
2) Pratikhura = Garbha presents with head, hands & feet together.
3) Beejaka = Only the head and one hand of Garbha is expelled.
4) Parigha = Garbha obstructs Yonimukha transversely.

B) Detailed classification: - 8
1) Presenting with both thighs (footling presentation in incomplete breech)
2) One thigh presenting, other flexed (footling p. in incomplete breech)
3) Presenting with buttocks (Kilaka – incomplete or complete breech)
4) Chest, flank or back presentation (Parigha – transverse lie in dorso-posterior
and dorso-anterior position)
5) Head at flanks and delivery with one hand (Beejaka – hand prolapse in
transverse lie or vertex presentation)
6) Flexed head with both hands (compound presentation)
7) Presenting with both hands, legs and head together (Pratikhura –
exaggerated flexion of transverse lie)
8) One foot in vagina and other in rectum (due to rupture of lower uterine
segment along with perforation of colon or rectum)
Sadhya-Asadhyata: 1-6 Sadhya; 7-8 Asadhya = Asadhya Gati = Viskambha
 Wondershare
PDFelement

 Asadhyata:
Mudhagarbha becomes Asadhya if following conditions occur:
- Garbhakosha
- Aparasanga
- Makkalla
- Yonisamvarana
- Yonisankocha
- Yonibhramsha
- Viparitendriya-artha (perception of opposite thigs by sensory organs)
- Viskambha (required Shastra Karma)
- Akshepa

 Samanya Chikitsa:
- Vatashamana -> Garbhasanga & Aparasanga Chikitsa
- Mantra Chikitsa (Atharva Veda)
- Shastra Karma (only done by a surgeon with practical experience)

 Shastra Karma:
- Manual removal by hand:
1) Contraindication of ingestion of food before surgical procedure.
2) Consent of guardian before surgical intervention. (Adhipatiajnya)
3) The woman should be in supine position with flexed thigh, hips are elevated
by keeping a thick pad of cloths. The vagina and hand should be lubricated
with mucinous substance or gum of Dhanwana, Nagavrittika, Salmali and
Ghrita.
4) The foetus should be extracted by inserting the hand.

- Shastra used to extract the Mudhagarbha:

1) Mandalagra (circular knife or round head knife, decapitating knife)
2) Angulisastra (finger knife)
3) Sanku (hook)
4) Ardhachandra (curved knife)

- Types of Shastra karma:

1) Utkarshana (pushing the foetus upwards)
2) Apakarshana (dragging the foetus downwards)
3) Sthanapavartana (rotation or cephalic version)
4) Udvartana (pushing the face upwards)
5) Utkartana (cutting)
6) Bhedana (perforation)
7) Chedana (excision)
8) Pidana (compression)
 Wondershare
PDFelement

 Prolonged Labour / Dysfunctional Labour

(Vilambita Prasava)

The labour is said to be prolonged when the combined duration of the first and second
stage is more than the time limit of 18 hours.
The prolongation may be due to protracted cervical dilatation in the first stage and/or
inadequate descent of the presenting part during the first or second stage of labour.

Prolonged labour is not synonymous with inefficient uterine contraction. Inefficient

uterine contraction can be a cause of prolonged labour, but labour may also be
prolonged due to pelvic or foetal factors.

 Prolonged Latent Phase

Latent phase is the preparatory phase of the uterus and the cervix before the
actual onset of labor.
Mean duration of latent phase is about 8 hours in a primi and 4 hours in a multi.
A latent phase that exceeds 20 hours in primigravidae or 14 hours in multiparae is
abnormal.
Prolonged latent phase may be worrisome to the patient but does not endanger
the mother or foetus.

Management:
- Rest and analgesic are usually given.
- When augmentation is decided, medical methods (oxytocin or prostaglandins)
are preferred. Amniotomy is usually avoided.
- Prolonged latent phase is not an indication for cesarean delivery.

 Causes for Prolonged Labour:

1) First stage
-> Fault in power: Abnormal uterine contraction such as uterine inertia
(common) or incoordinate uterine contraction
-> Fault in the passage: Contracted pelvis, Cervical dystocia, Pelvic tumor or
full bladder
-> Fault in the passenger: Malposition(occipitoposterior), Malpresentation
(face, brow), Congenital anomalies of the foetus (hydrocephalus)

2) Second stage
-> Fault in the power: Uterine inertia, Inability to bear down, Regional
(epidural) analgesia, Constriction ring
-> Fault in the passage: Cephalopelvic disproportion, Android pelvis,
Contracted pelvis, Undue resistance of the pelvic floor or perineum due to
spasm or old scarring, Soft tissue pelvic tumor
-> Fault in the passenger: Malposition (occipitoposterior), Malpresentation,
Large foetal size, Congenital anomalies of the foetus
 Wondershare
PDFelement

 Diagnosis:
- Prolonged labour is not a diagnosis but it is the manifestation of an abnormality,
the cause of which should be detected by a thorough abdominal and vaginal
examination.
- During vaginal examination, if a finger is accommodated in between the cervix
and the head during uterine contraction pelvic adequacy can be reasonably
established.
- Intranatal imaging (radiography, CT or MRI) is of help in determining the foetal
station and position as well as pelvic shape and size.
- First stage of labor is considered prolonged when the duration is more than 12
hours.
- Mean duration of second stage is 50 minutes for nullipara and 20 minutes in
multipara. Prolonged second stage is diagnosed if the duration exceeds 2 hours in
nullipara and 1 hour in a multipara when no regional anesthesia is used.
One hour or more is permitted in both the groups when regional anesthesia is
used during labour.

 Complications: Increased maternal & foetal morbidity & mortality.

1) Maternal
- Distress, Chorioamnionitis, PPH
- Trauma to the genital tract concealed (undue stretching of the perineal
muscles which may be the cause of prolapse at a later period) or revealed
such as cervical tear, rupture of uterus
- Increased operative delivery
- Puerperal sepsis, Subinvolution

2) Foetal
- Distress, Intrauterine infection
- Hypoxia due to diminished uteroplacental circulation, especially after
rupture of the membranes.
- Intracranial stress or haemorrhage following prolonged stay in the
perineum and/or supermoulding of the head.
- Increased operative delivery

 Management:
Careful evaluation is to be done to find out:
1) Cause of prolonged labour
2) Effect on the mother
3) Effect on the foetus

In a nulliparous patient, inadequate uterine activity is the most common cause of

primary dysfunctional labour.
In a multiparous patient, cephalopelvic disproportion (due to malposition) is the
most common cause.
 Wondershare
PDFelement

1) First stage delay:

Vaginal examination is done to verify the foetal presentation, position and
station. Clinical pelvimetry is done.
If only uterine activity is suboptimal:
- Amniotomy and/or oxytocin infusion is adequate,
- Effective pain relief is given by intramuscular pethidine or by regional
(epidural) analgesia.
- Caesarean section is done when vaginal delivery is unsafe
(malpresentation, malposition, large foetus or CPD).

2) Second stage delay:

Short period of expectant management is reasonable provided the FHR is
reassuring and vaginal delivery is imminent. Otherwise appropriate assisted
delivery, vaginal (forceps, ventouse) or abdominal (caesarean) should be
done.

-> Uterine Inertia / Hypotonic Uterine Action

In uterine inertia, the pattern of uterine contractions is normal, but the intervals
between the contractions are long (< 3 in 10 minutes), and the duration of contraction is
short (< 40 seconds) with weak intensity.
The contractions usually improve after rupture of membranes, thereafter the progress is
normal. Inadequate uterine action is the most common cause in nullipara and very
unlikely in multipara.

-> Hypertonic Uterine Contractions (Precipitate Labour)

Precipitate labour is an overactive labour when the baby is expelled soon after the onset
of labour. The pattern of contraction is normal, but the frequency and intensity of
uterine contractions is increased.
Maternal risk: Laceration of cervix and perineum, PPH, AFE
Foetal risk: Foetal hypoxia, Intra-cranial haemorrhage, Skull fractures, Cord rupture

-> Cervical Dystocia

Cervical dystocia is a difficult labour and delivery caused by mechanical obstruction at
the cervix.
Dystocia comes from the Greek "dys" meaning "difficult, painful, disordered, abnormal"
+ "tokos" meaning "birth."

1) Primary: Unyielding cervix after many hours of labour. Cervix is effaced and well
applied to the engaged head but has a firm ring and does not dilate normally. A ring of
cervix or portion of anterior lip may be avulsed due to continuous pressure of the head.

2) Secondary: This type is caused due to organic changes in the cervix. The cervix does
not dilate in labour due to previous obstetric injury, cone biopsy or amputation of cervix.
 Wondershare
PDFelement

-> Obstructed Labour

Obstructed labour is the situation in which there is a mechanical obstruction preventing
the presenting part to descend. It is characterized by failure of labour progress despite
presence of strong uterine contractions.

 Cause:
1) Maternal: Contracted pelvis, Pelvic tumors, Uterine fibroids, Large ovarian
tumors, Tumors of pelvic bones, rectum or bladder, Pelvic kidney,
Sacculation of uterus, Constriction ring of uterus

2) Foetal: Large size (macrosomia), Malpresentation, Compound presentation,

Mentoposterior position, Transverse or oblique lie, Malformation of foetus,
Hydrocephalus, Foetal abdominal tumors, Conjoined twins, Locked twins

 Clinical Features & Complications:

- Early rupture of membranes
- Extreme moulding and large caput causing elongation of the head
- Maternal & foetal distress
- Retractions of placental site leading to foetal hypoxia
- Secondary uterine inertia in primigravida
- Overdistension of lower segment, threatened uterine rupture in multigravida
- PPH

 Diagnosis:
- Partogram helps in easy and early recognition of an impending obstruction.
- Clinical features and condition of the mother and foetus (FHS)
- Per abdomen examination: Retraction ring is seen and felt
- Pervaginal examination: Vulva is swollen, oedematous, Vagina is dry, hot, there is
offensive purulent discharge. Cervix is fully dilated. Presenting part is extremely
moulded and obstructed.

 Management:
- IV fluids to correct dehydration
- Sodium bicarbonate to correct acidosis
- Antibiotics
- Vaginal delivery is attempted in thepresence of an experienced obstetrician by
increasing the size of the pelvis (symphysiotomy) or by decreaing the size of foeuts
by destructive operation (craniotomy, decapitation, evisceration). Oxytocics are
contraindicated.
- Caesarean section is commonly practiced.
- Laparotomy is undertaken when uterine rupture is suspected. Extensive irregular
tear involves major vessels requiring hysterectomy.
 Wondershare
PDFelement

 Cephalopelvic Disproportion (CPD)

(Kukshivipatana)

Cephalopelvic disproportion may be due to a relatively large baby or contracted pelvis.

A contracted pelvis is defined as one in which any of thessential diametes is shortened so
as to alter the normal mechanism of labour.

 Cause:
- Abnormal pelvis: Contracted pelvis
- Abnormal maternal soft tissues: Ovarioan tumors, Fibroid uterus
- Foetal anomalies: Hydrocephalus, Macrosomia, Conjoined/locked twins, etc.
- Large foetal size

 Disproportion: - 2
1) Absolute: When under no circumstance the baby can pass safely through the
birth passage.
2) Relative: When other factors contribute (such as maternal soft tissues) to
the problem, minor degress can be overcome with efficient uterine
contratctions.

 Diagnosis:
- Medical history of rickets, TB, fractured pelvis, limp or abnormal gait, etc.
- Obstetric history gives definite clues to probable presenceof contracted pelvis:
Previous prolonged labour, Previous still birth, Baby born with asphyxia, History of
neonatal convulsions/mental retardation, Previous instrumental delivery, History
of serious maternal injury to soft tissues, Appearance of patient -> small stature,
pendulous abdomen, exaggerated spinal curvature.
- Vaginal examination
- Clinical pelvimetry
- Muller’s muno-kerr method

 Management:
- Suspected contracted pelvis
a) Minor contracted pelvis -> Trial labour, Trial forceps in 2nd stage -> if Trial
labour fails -> CS

b) Severe contracted pelvis, Medical disorders like DM, HTN, etc., True
conjugate (< 9 cm), Elderly primigravida, Breech, IUGR, Previous caesarean
section -> CS

- Foetal causes -> Craniotomy, Symphysiotomy

 Wondershare
PDFelement

 Preterm Labour (PTL)

(Purvakalika Prasava)

Preterm labour (PTL) is defined as one where the labour starts before the 37th completed
week (< 259 days), counting from the first day of the last menstrual period.
The lower limit of gestation is not uniformly defined; whereas in developed countries it
has been brought down to 20 weeks, in developing countries it is 28 weeks.
Preterm birth is a significant cause of perinatal morbidity and mortality.

 Incidence: The prevalence widely varies and ranges between 5-10%.

 Cause: In about 50%, the cause of preterm labour is not known. Often it is
multifactorial.

 Risk factors:
1) History: Previous history of induced or spontaneous abortion or preterm
delivery; Pregnancy following assisted reproductive techniques (ART);
Asymptomatic bacteriuria or recurrent urinary tract infection; Smoking
habits, Low socioeconomic and nutritional status and maternal distress.

2) Complications in present pregnancy:

a) Maternal
i) Pregnancy complications: Pre-eclampsia, APH, PROM,
polyhydramnios
ii) Uterine anomalies: Cervical incompetence, malformation of uterus
iii) Acute diseases: Acute fever, acute pyelonephritis, diarrhoea, acute
appendicitis, toxoplasmosis and abdominal operation.
iv) Chronic diseases: Hypertension, nephritis, diabetes, decompensated
heart lesion, severe anemia, low body mass index (LBMI)
v) Genital tract infection: Bacterial vaginosis, beta-hemolytic
Streptococcus, bacteroides, chlamydia and mycoplasma

b) Foetal: Multiple pregnancy, congenital malformations, IUFD

c) Placental: Infarction, thrombosis, placenta previa, abruption placentae

 Diagnosis:
- Regular uterine contractions with or without pain (at least one in every 10
minutes)
- Dilatation (> 2 cm) and effacement (80%) of the cervix
- Length of the cervix (measured by TVS) < 2.5 cm and funneling of the internal os
- Pelvic pressure, backache and/or vaginal discharge or bleeding. It is better to
overdiagnose preterm labour than to ignore the possibility of its presence.
- Preterm labour is very unlikely when cervical length is > 30 mm, irrespective of
uterine contractions.
 Wondershare
PDFelement

 Management:
1) To prevent preterm onset of labour (if possible)
2) To arrest preterm labour (if not contraindicated)
3) Appropriate management of labour
4) Effective neonatal care

1) Prevention of Preterm Labour

i) Primary care is aimed to reduce the incidence of preterm labour by
reducing the high-risk factors.
ii) Secondary care includes screening tests for early detection and
prophylactic treatment.
iii) Tertiary care is aimed to reduce the perinatal morbidity and mortality
after the diagnosis.

2) Measures to arrest Preterm Labour

Only in a negligible proportion of cases (about 10-20%) where the foetus is
not compromised, the maternal condition remains good and membranes are
intact, the following regime may be instituted in an attempt to arrest
premature labor.
- Bed rest the patient is to lie preferably in left lateral position though the
benefits are doubtful.
- Adequate hydration is maintained.
- Prophylactic cervical cerclage for women with prior preterm birth and short
cervix in the present pregnancy may be beneficial.
- Tocolytic agents: Various drugs such as nifedipine, atosiban, progesterone
(micronized) have been used to inhibit uterine contractions.
- Contraindications:
a) Maternal: Uncontrolled diabetes, thyrotoxicosis, severe
hypertension, cardiac disease, haemorrhage in pregnancy, e.g.
placenta previa or abruption.
b) Foetal: Foetal distress, foetal death, congenital malformation and
pregnancy beyond 34 weeks.
c) Others: Rupture of membranes, chorioamnionitis and cervical
dilatation more than 4 cm.
 Wondershare
PDFelement

3) Management of Labour
- To prevent birth asphyxia and development of RDS.
- To prevent birth trauma.
- Duration of laboor is usually short.

a) First Stage: The patient is put to bed to prevent early rupture of the
membranes. To ensure adequate foetal oxygenation by giving oxygen to the
mother by mask. Epidural analgesia is of choice. Labour should be carefully
monitored preferably with continuous EFM. Cesarean delivery is done for
obstetric reasons only (hypertension, abruption or malpresentation).

b) Second Stage: The birth should be gentle and slow to avoid rapid
compression and decompression of the head. Episiotomy may be done to
minimize head compression if there is perineal resistance. Tendency to delay
is curtailed by low forceps. As such, routine forceps delivery is not indicated.

c) Place of cesarean section: Routine cesarean delivery is not

recommended. Preterm foetuses before 34 weeks presented by breech are
generally delivered by cesarean section. Lower segment vertical or J-shaped
incision may have to be made to minimize trauma during delivery.

4) Neonatal care
The cord is to be clamped quickly to prevent hypervolemia and development
of hyperbilirubinemia. The cord length is kept long (about 10-12 cm) in case
exchange transfusion is required.
- The air passage should be cleared of mucus promptly by gently using a
mucus sucker. Adequate oxygenation through mask or nasal catheter in
concentration not exceeding 35%.
- The baby should be wrapped, including head, in a sterile warm towel
(normal temperature 36.5-37.5°C) to maintain a relatively stable
thermoneutral condition; keep the delivery room warm and dry; keep the
baby with mother-skin-to-skin contact.
- Aqueous solution of vitamin K 1 mg is to be injected intramuscularly to
prevent hemorrhagic manifestations.
- Prevent infection
- Maintain nutrition
 Wondershare
PDFelement

 Postterm Labour
(Kalatita Garbha-Avastha)

Any pregnancy which has passed beyond the expected date of delivery, is called a
prolonged or postdated pregnancy. Definition by WHO and IFGO (International
Federation of Gynaecology and Obstetrics): A labour is termed as postterm if 42 weeks
(294 days) or more have been completed.

 Incidence: 6-8% of pregnancies go beyond 42 weeks.

 Factors related with postterm pregnancy:

- Wrong dates due to inaccurate LMP (most common)
- Biological variability (hereditary) may be seen in the family
- Maternal factors: Primiparity, previous prolonged pregnancy, sedentary habit,
elderly multiparae
- Foetal factors: Congenital anomalies: Anencephaly → abnormal foetal HPA axis
and adrenal hypoplasia → diminished fetal cortisol response
- Placental factors: Sulfatase deficiency → low estrogen

 Diagnosis:
Every possible effort should be made with available resources to diagnose at least
the maturity of the foetus, if not the postmaturity.
The important dates to determine foetal gestational age are:
- Date of LMP
- Early ultrasound dating
- Timing of intercourse

 Complications of Postterm Pregnancy:

1) Placental: Risk of placental insufficiency due to placental aging; placental
calcification and infarction. Associated complications like hypertension and
diabetes aggravates the pathology.

2) Maternal: There is increased morbidity, incidental to hazards of induction,

instrumental and operative delivery. Postmaturity per se does not put the
mother at risk.

3) Foetal:
a) During pregnancy: Diminished placental function, oligohydramnios
and meconium stained liquor. These lead to foetal hypoxia and foetal
distress.
b) During labuor: Foetal hypoxia and acidosis; Labour dysfunction;
Meconium aspiration; Risks of cord compression due to oligohydramnios;
Shoulder dystocia; Increased incidence of birth trauma due to big size baby
and non-molding of head due to hardening of skull bones; Increased
incidence of operative delivery.
 Wondershare
PDFelement

c) Following birth: Chemical pneumonitis, atelectasis and pulmonary

hypertension are due to meconium aspiration; Hypoxia (low Apgar scores)
and respiratory failure; Hypoglycemia & polycythemia; Increased NICU
admissions. Perinatal morbidity and mortality is calculated in terms of
stillbirth.

 Management:
One should be certain about the maturity of the foetus. Increased foetal
surveillance is maintained. Perinatal morbidity and mortality are increased when
pregnancy continues beyond 41 weeks. Induction of labour may be considered at
or beyond 41 weeks. Timely delivery reduces the risk of stillbirth. Increased foetal
surveillance (twice weekly) is maintained when conservative management is done.
For the formulation of management, the cases are grouped into:
1) Uncomplicated
2) Complicated

1) Uncomplicated
- Selective induction: In this regime, the pregnancy may be allowed to
continue until spontaneous onset of labour occurs. Foetal surveillance is
continued with modified biophysical profile twice a week.
- Routine induction: The expectant attitude is extended for 7-10 days past
the expected date and thereafter labour is induced.
- Induction: Induction of labour reduces the rate of caesarean delivery and
perinatal mortality.
If the cervix is favorable (ripe), induction is to be done by stripping of the
membranes or by low rupture of the membranes. If the liquor is found clear,
oxytocin infusion is added to be more effective. Careful foetal monitoring is
mandatory.
If the cervix is unripe, it is made favorable by vaginal administration of PGE2
gel. This is followed by low rupture of the membranes. Oxytocin infusion is
added when required. Cervical length (TVS) < 25 mm is a predictor of
successful induction of labour.

2) Complicated
Elective caesarean section is advisable when postmaturity is associated with
high risk factors like: Elderly primigravidae, pre-eclampsia, Rh-
incompatibility, foetal compromise, oligohydramnios or associated
complications that are likely to produce placental insufficiency.
 Wondershare
PDFelement

 Induction and Augmentation of Labour

Induction of labour and augmentation of labour are performed for different indications
but the methods are the same.

Induction of labour: stimulating the uterus to begin labour.

Augmentation of labour: stimulating the uterus during labour to increase the frequency,
duration and strength of contractions.

A good labour pattern is established when there are three contractions in 10 minutes,
each lasting more than 40 seconds.

 Assessment of the Cervix:

The success of induction of labour is related to the condition of the cervix at the
start of induction. To assess the condition of the cervix, a cervical exam is
performed and a score is assigned based on the criteria in the table:

Assessment of cervix for induction of labour

Factor Rating
0 1 2 3

Dilatation (cm) more than

closed 1–2 3–4
5
more than
Length of cervix (cm) 3–4 1–2 less than 1
4
Consistency Firm Average Soft -
Position Posterior Mid Anterior -
Descent by station of head (cm from ischial -2 -1, 0 +1, +2
-3
spines)
Descent by abdominal palpation (fifths of head 4/5 3/5 2/5 1/5
palpable)

If the cervix is favourable (has a score of 6 or more), labour is usually successfully induced
with oxytocin alone.
If the cervix is unfavourable (has a score of 5 or less), ripen the cervix using prostaglandins or
a Foley catheter before induction.
 Wondershare
PDFelement

 Oxytocin:
Use oxytocin with great caution as foetal distress can occur from hyperstimulation
and, rarely, uterine rupture can occur. Multiparous women are at higher risk for
uterine rupture.

The effective dose of oxytocin varies greatly between women.

Cautiously administer oxytocin in IV fluids (dextrose or normal saline), gradually
increasing the rate of infusion until good labour is established (three contractions
in 10 minutes, each lasting more than 40 seconds). Maintain this rate until
delivery. The uterus should relax between contractions.

If there are not three contractions in 10 minutes, each lasting more than 40
seconds per minute, increase the oxytocin infusion rate.

If labour still has not been established using the higher concentration of oxytocin:
- In multigravida and in women with previous caesarean scars, induction has
failed; deliver by caesarean section;
- In primigravida, infuse oxytocin at a higher concentration.
-> Infuse oxytocin 10 units in 500 mL dextrose (or normal saline) at 30 drops per
minute;
-> Increase infusion rate by 10 drops per minute every 30 minutes until good
contractions are established;
-> If good contractions are not established at 60 drops per minute (60 mIU per
minute), deliver by caesarean section.

 Prostaglandins:
E1, E2, F2α are the three main prostaglandins used clinically. All of them have
potent oxytocic effect on the pregnant uterus. It is used for pre-induction ripening,
induction and augmentation of labour.

PGE1 (Misoprostol) available as tablet is administered in 25 mcg dose, but it is still

not approved by FDA for induction of labour at term.

PGE2 (Dinoprostone) available as gel is applied intra-cervical (0.5 mg) and intra-
vaginally (3 mg). Cervix is reassessed after 6 hours.

PGF2α (Carboprost), when injected into the body or amniotic sac, can induce
labour. In small doses (1-4 mg/day), PGF2α acts to stimulate uterine muscle
contractions, which aids in the birth process.
 Wondershare
PDFelement

 Artifical Rupture of Membranes (ARM) / Amniotomy:

In some cases, if the membranes are intact, amniotomy is considered and to
induce labour. Membrane rupture, whether spontaneous or artificial, often sets
off the following chain of events:
- Amniotic fluid is expelled
- Uterine volume is decreased
- Prostaglandins are produced, stimulating labour
- Uterine contractions begin (if the woman is not in labour) or become stronger (if
she is already in labour).

Procedure:
- Listen to and note the foetal heart rate.
- Ask the woman to lie on her back with her legs bent, feet together and knees
apart.
- Wearing high-level disinfected gloves, use one hand to examine the cervix and
note the consistency, position, effacement and dilatation.
- Use the other hand to insert an amniotic hook or a Kocher clamp into the vagina.
- Guide the clamp or hook towards the membranes along the fingers in the vagina.
- Place two fingers against the membranes and gently rupture the membranes
with the instrument in the other hand. Allow the amniotic fluid to drain slowly
around the fingers.
- Note the colour of the fluid (clear, greenish, bloody). If thick meconium is
present, suspect foetal distress.
- After ARM, listen to the foetal heart rate during and after a contraction. If the
foetal heart rate is abnormal (less than 100 or more than 180 beats per minute),
suspect foetal distress.
- If good labour is not established 1 hour after ARM, begin oxytocin infusion.
- If labour is induced because of severe maternal disease (e.g. sepsis or eclampsia),
begin oxytocin infusion at the same time as ARM.
 Wondershare
PDFelement

 Maternal Distress
(Garbhini Klesha)

Delayed or insufficient presence of Avi causes Klesha to both, Garbhini and Garbha.
Garbhini Lakshana: Akshini & Asya Srasta (sunken eyes, anxious look), Kricchra-Shvasa,
Putigandha, Shuska Jihva-Talu

Maternal distress is an emergency situation warranting immediate action during labour.

It is a do or die situation where saving the mother is the prime goal.

 Signs:
- Sunken eyes, anxious look, Dehydration (dry tongue, thirst)
- Vagina: Hot, dry, foul smelling discharge
- Acetone smell in breath
- Oliguria, Acetonuria, Dark coloured urine
- Tachycardia
- PR ≥ 100/min

 Management:
- Intravenous fluid
- Oxygen
- Delivery at the earliest is the main treatment; either assisted delivery or
caesarean section as per demand of the stage or status of labour.

 Foetal Distress
(Garbha Klesha)

Foetal distress is a state in which normal foetal function is deranged so as to casue death
or permanent injury to a foetus in utero.
It implies impairment of foetal gaseous exchange resulting in hypoxia (foetal
hypercarbia).

Acute foetal distress means bradycardia with meconium stained in liquor.

Chronic foetal distress means IUGR with low volume of liquor.

 Causes:
1) Maternal
- Respiratory depressions (cardiac failure, chest infection, eclampsia, etc.)
- Hypotension (haemorrhage, shock, spinal anesthesia, etc.)
- Hypertension (leads to placental insufficiency)
- Severe anemia (reduces oxygen supply)
- Maternal acidosis
 Wondershare
PDFelement

2) Uterine
- Excessive retraction of upper uterine segment and placental site
compresses maternal sinuses. It usually occurs in prolonged labour with
liquor drained away.
- Oversue of oxytocics (causing uterine hyperstimulation and placental
ischemia)

3) Placenta
- Placenta previa, Abruptio placentae
- Placental insufficiency

4) Umbilical cord
- Prolapse, Knots
- Entangled tightly around the foetal neck

5) Foetal
- Excessive moulding
- Congenital heart disease
- Local anasthetics

 Management:
1) Assessment of degree of foetal distress
- Non-stress test (NST - monitoring of foetal heart rate)
- Contraction stress test (to evaluate placental ability to provide oxygen)
- Amnioscopy (to detect meconium staining)
- Pelvic examination (to rule out cord prolapse)

2) Attempts to improve foetal status in utero

- Correction of maternal distress (if present)
- Encourage the mother to lie on her side to avoid supine hypotension.
- Rapid blood volume replacement in APH.
- Correction of maternal acidosis with IV NaHCO3.
- Avoid liberal use of IV fluids during labour.
- Decrease uterine activity.

3) Removal of foetus from its unfavourable environment

- Indicated in the presence of an obvious cause for foetal distress. Method of
delivery depends on cervical dilatation, position and presentation of the
foetus.
- Vaginal delivery by forceps/ventuose delivery in 2nd stage.
- CS if vaginal delivery is not possible.

4) Neonatal Care
Immediate resuscitation, intubation, oxygenation, correction of acidosis.
 Wondershare
PDFelement

 Caesarean Section / C-Section (CS)

Caesarean section is abdominal delivery of the foetus by placing an incision over the
abdominal wall and the uterine wall after 28 weeks of pregnancy.
Incidence: 8-16%

 Types:
1) Transperitoneal - Lower Segment Caesarean Section (LSCS) 96%; Classical or
upper segment (rarely performed)
2) Extraperitoneal - Not performed, in modern obstetrics
3) Caesarean hysterectomy - performed in specific cases

 Indications:
1) Maternal
- Contracted pelvis, previous LSCS, PIH, Pre-eclampsia, Eclampsia
- Selected cases of diabetes or Rh-incompatibility, HIV positive
- Failure in progress of labour, Cervical dystocia, Abnormal uterine
contractions
- Failed induction of labour, Failed trial labour, Failed forceps delivery

2) Foetal
- Foetal distress during first stage of labour
- Cord prolapse before full dilatation
- Recurrent pregnancy wastage
- Repeated unexplained IUFD, Intrapartum death, IUGR, Large foetal size
- Hyperextended head
- Prematurity with good survival chances, Postmaturity

3) Malpresentation
Shoulder, Brow, Face mentoposterior, Breech, Breech with elderly primi,
Footling presentation

4) Multiple pregancy
- Both breech, First transverse
- Foetal distress in first baby
- Conjoined twins locked twins

 Method:
- Written consent
- Pre-operation - in emergency cases full pre-operative preparation may not be
possible.
- Part preparation
- Physical fitness (anaesthetic)
- Investigation if necessary - BgRh, cross matching
- Previous report & USG report
- Pre-op vital data & P/A examination
 Wondershare
PDFelement

1) Preparation for CS
- Intravenous line with wide bore needle is set up. Folys catheter is kept.
- Inj. Atropine 0.6 mg half an hour before the operation. Prophylactic
antibiotics should be given (IV) before making the skin incision. Ranitidine (H
blocker) is (50 mg IM or IV) 1 hour before the surgery. Metoclopramide (10
mg IV) is given.
- Blood is sent for grooping & cross matching. Keep BT ready. Local
preparation i.e. Abdomen and back.
- Neonatologist should be made available.

2) Anesthesia
Spinal, epidural or general. However, choice of the patient and urgency of
delivery are also considered. Spinal anesthesia is the most commonly used.

3) Position of the patient

The patient is placed in dorsal position. In susceptible cases, to minimize any
adverse effects of venacaval compression, a 15-degree tilt to her left using a
wedge until delivery of the baby should be done.

4) Antiseptic painting
The abdomen is painted with 7.5% povidone-iodine solution or savlon lotion
and should be properly draped with sterile towels.

5) Incision on the abdomen

Abdomen is opened in layers commonly by Pfannenstiel incision (low
transverse). Parital peritoneum is opened in upper part of the incision to
avoid the bladder. With scissors, the peritoneal incision is extended above
and down. Doyen retractor is introduced in the lower end of the incision and
the uterus is exposed. Loose visceral peritoneum of the lower uterine
segment is identified, lifted with toothless forceps and small transverse cut is
put by scissors. Visceral peritoneum is dissected on either side by passing
scissors between it and lower uterine segment and then the incision is
extnded on both sides. The lower peritoneal flaps are lifted up with forceps
and by finger pressure or swab on holder, it is pushed down for about 3-5 cm
along with the bladder. Doyen retractor is adjusted to retract the bladder.
Site of the incision of lower segment is judged by the station of the
presenting part. It should beat the level of maximum transverse diameter of
the presenting part. One hand is passed in the uterus below the head, doyen
retractor is removed. Head is flexed and delivery by hand in combination
with fundal pressure is done. Neonate is handed over to the neonatologist.
Angles and edges of the lower uterine segment are caught with swab holders
or allis forceps. The placenta is delivered by gentle cord traction and fundal
pressure. Only if it does not seperate readily it can be removed manually.
Care must be taken to remove the membranes completely. Uterine cavity is
explored as a routine before closure.
 Wondershare
PDFelement

 Post-operative Care:
1) First 24 hours: (Day 0) Observation for the first 6-8 hours is important.
Periodic checkup of pulse, BP, amount of vaginal bleeding and behaviour of
the uterus is done and recorded.

Fluid: Sodium chloride (0.9%) or Ringer’s lactate drip is continued until at

least 2.0-2.5L of the solutions are infused. Blood transfusion is helpful in
anemic mothers for a quick post-operative recovery. Blood transfusion is
required if the blood loss is more than average during the operation (average
blood loss in cesarean section is approximately 0.5-1L).

Oxytocics: Injection oxytocin 5 units IM or IV (slow) or methergine 0.2 mg IM

is given and may be repeated. Prophylactic antibiotics (cephalosporins,
metronidazole) for all caesarean deliveries is given for 2-4 doses. Therapeutic
antibiotic is given when indicated. Analgesics in the form of pethidine
hydrochloride is administered and may have to be repeated.

Ambulation: The patient can sit on the bed or even get out of bed to
evacuate the bladder, provided the general condition permits. She is
encouraged to move her legs and ankles and to breathe deeply to minimize
leg vein thrombosis and pulmonary embolism. Baby is put to the breast for
feeding after 3-4 hours when mother is stable and relieved of pain.

2) Day 1: Oral feeding in the form of plain or electrolyte water or raw tea may
be given. Active bowel sounds are observed by the end of the day.

3) Day 2: Light solid diet of the patient’s choice is given. Bowel care: 3-4
teaspoons of lactulose is given at bed time, if the bowels do not move
spontaneously.

4) Day 5 or day 6: The abdominal skin stitches are to be removed on the D-5 (in
transverse) or D-6 (in longitudinal).

5) Discharge: The patient is discharged on the day following removal of the

stitches, if otherwise fit. Usual advices like those following vaginal delivery
are given. Depending on postoperative recovery and availability of care at
home, patient may be discharged as early as third to as late as seventh
postoperative days.
 Wondershare
PDFelement

 Assisted Delivery / Instrumental Delivery

Delivery is called assisted delivery or instrumental delivery when forceps or ventouse
suction cup are used to help deliver the baby.
Assisted delivery is less common in women who have had a spontaneous vaginal birth
before.

 Indications for Operative Vaginal Delivery: (Forceps / Ventouse Delivery)

1) Maternal
- Inadequate expulsive efforts
- Maternal exhaustion (distress)
- Where expulsive efforts (Valsalva) are to be avoided e.g. cardiac disease,
hypertensive crisis, cerebrovascular diseases, spinalcord injury

2) Foetal
- Non-reassuring foetal heart rate - foetal distress (e.g. low-birth-weight
baby, postmaturity)
- After-coming head of breech
- Suspicion of foetal compromise

3) Other
- Prolonged second stage of labour (nullipara >2 hour; multipara >1hour)
- To cut short the second stage of labour in severe pre-eclampsia, cardiac
disease, postcaesarean pregnancy

 Contraindications for Operative Vaginal Delivery: (Forceps / Ventouse Delivery)

- Unengaged foetal head
- Obvious CPD
- Foetus having unacute bleeding diathesis (haemophilia)
- Patient’s refusal

 Prerequisits for Operative Vaginal Delivery: (Forceps / Ventouse Delivery)

1) Foetal and Maternal Criteria
- Foetal head engaged (head ≤ 1/5 palpable per abdomen)
- Cervix must be fully dilated
- Membranes must be ruptured
- Foetal head position is exactly known
- Pelvis deemed adequate
- Bladder must be emptied
- Adequate maternal analgesia
- Informed consent (verbal or written) with prior clear explanation

2) Others
- Experienced operator
- Aseptic techniques
- Back up plan and facilities in case of failure
- Presence of a neonatologist
- Willingness to abandon the procedure when difficulties occur
 Wondershare
PDFelement

-> Forceps Delivery

Obstetric forceps is a pair of instruments, especially designed to assist extraction of the
foetal head and thereby accomplishing delivery of the foetus.

 Varieties:
Three varieties of forceps are commonly used:
i) Long-curved forceps with or without axis-traction device
ii) Short-curved forceps / Wrigley’s forceps
iii) Kielland’s forceps

 Parts of Forceps:
The basic construction of these forceps is the
same; each consists of two halves (blades),
articulated by a lock.
Forceps can be devided into:
- Handle
- Shank
- Lock
- Fenestrated blade (pelvic curve, cephalic curve)

 Steps of Forceps Delivery:

1) Identification of the blades and their application
2) Locking of the blades
3) Traction
4) Removal of the blades
 Wondershare
PDFelement

 Complications of Forceps Delivery:

1) Maternal:
Immediate
- Injury: Vaginal laceration or sulcus tear, cervical tear, extension of
episiotomy to involve the vaginal vault, complete perineal tear
- Nerve injury: Femoral (L2 – L4), lumbosacral trunk (L4, L5)
- Postpartum hemorrhage may be (i) traumatic or (ii) atonic, requiring blood
transfusion or (iii) both, may cause shock
- Anesthetic complications
- Puerperal sepsis and maternal morbidity

Remote
Painful perineal scars, dyspareunia, low backache, genital prolapse, urinary
incontinence, anal sphincter dysfunction

2) Foetal / Neonate:
Immediate
Asphyxia, facial bruising, intracranial hemorrhage, cephalohaematoma, facial
palsy, skull fractures, cervical spine injury (rotational forceps

Remote:
Cerebral or spastic palsy due to residual cerebral injury (rare)

-> Ventouse Delivery

Ventouse is an instrumental device designed to assist delivery by creating a vacuum
between it and the foetal scalp.
The pulling force is dragging the cranium while in forceps, the pulling force is directly
transmitted to the base of the skull.

 Instruments:
Ever since Malmstrom, in 1956 reintroduced and popularized its use, various
modifications of the instruments are now available. Each, however, consists of the
following basic components:
 Wondershare
PDFelement

 Steps:
1) Application of the cup
2) Traction
3) As soon as the head is delivered, the vacuum is reduced by opening the
screw-release valve and the cup is then detached. The delivery is then
completed in the normal way.

 Complications:
1) Maternal: Injuries are uncommon but occur due to inclusion of soft tissues
such as the cervix or vaginal wall inside the cup.

2) Foetal / Neonate:
- Superficial scalp abrasion, sloughing of the scalp, cephalohaematoma
- Subaponeurotic haemorrhage, intracranial hemorrhage, retinal
hemorrhage
- Jaundice

 Version
Version is an operation by which one presentation is substituted for another more
favourable one by manipulation of foetus in utero.

 Types:
1) External Version: All manipulations are done through external abdominal
wall, usually performed before onset of labour.
2) Internal Version: Manipulation is done under GA after labour has set it
because the cervix is dilated to permit entry of one hand into uterine cavity.
3) Bipolar Version: Rarely performed. Manipulation is done by acting upon
both poles of the foetus by either external or combined version.
4) Cephalic Version: Manipulation is done to achieve a cephalic presentation.
5) Podalic Version: Manipulation is done to achieve a breech presentation.

 External Version:
External version may be either cephalic or podalic. If cephalic version is not
successful, podalic version is done.
External version is recommended to be done at 35-37 weeks of gestation so that
the manipulated presentation does not revert back, and in the event of any
complication due to version, which mandates an immediate CS, the foetus is
mature enough to survive.

 Garbhasthithi Parivarthana:
Acharya Sushruta mentioned that if the foetus is overturned, it should be reversed
and brought back to normal position.
The breech is converted to vertex presentation; hence it is also known as Sthana-
apavartana.
 Wondershare
PDFelement

 Genital Tract Injuries during Labour

- Laceration of Perineum
- Laceration of Cervix
- Laceration of Anterior Vulva & Lower Anterior Vaginal Wall
- Laceration of Upper Vagina
- Vesicovaginal Fistula
- Haematoma
- Rupture of Uterus
- Inversion of Uterus

-> Laceration of Perineum / Perineal Tear

The perineum is the area between the vaginal opening and anus.
It is common for the perineum to tear to some extent during childbirth.
Tears can also occur inside the vagina or other parts of the vulva, including the labia.
Up to 9 in every 10 first time mothers who have a vaginal birth will experience some sort
of tear, graze or episiotomy. It is slightly less common for mothers who have had a
vaginal birth before.
For most women, these tears are minor and heal quickly.

 Types:
1) First-degree
2) Second-degree
3) Third-degree
4) Foruth-degree
First-degree tears affect only the skin. They usually heal quickly and do not
require treatment.
Second-degree tears affect the skin muscle of the perineum. They usually
require stitches.
Third- and Fourth-degree tears also known as obstetric anal sphincter injuries
(OASI), extend into the anal sphincter. These deeper tears need repair in an
operating theatre.

-> Laceration of Cervix / Cervical Tear

Small tears heal spontaneously and require no treatment. Deep lacerations can cause
severe haemorrhage and shock.

 Risk factors: Precipitate labour, Rigid/scarred cervix, Forceful extraction through

undilated cervix, Large foetal size, Breech extraction

 Repair: Cervix is exposed with vaginal speculum. Ring forceps is placed on the side
of each laceration. Interrupted or figure 8 suture is placed starting at the apex and
tied tightly to control the bleeding.
Tear extending into lower uterine segment or broad ligament may warrant
laparotomy.
 Wondershare
PDFelement

-> Laceration of Anterior Vulva & Lower Anterior Vaginal Wall

Superficial small lacerations do not need any repair. Deep or larger tears should have the
edges brought together with interrupted sutures to promote healing. Profuse bleeing is
best controlled by figure 8 sutures to include and shut off the torn and bleeding vessels.
If the suturing does not stop bleeding, a firm pack is applied on the bleeding site and
haemorrhage is controlled by the tamponade.
Repair of periclitorial area is difficult due to close proximity to urethra. Catheter is
inserted to preven damage to the urethra by guiding the needle away from it.

-> Laceration of Upper Vagina / Upper Vaginal Tear

Risk factors: Forceps rotations & extractions, Large foetal size, Improper traction,
Malpositions, Malpresentations
Repair: Upper vaginal lacerations usually bleed profusely. The apex of the tear is
included in the suturing. Figure 8 sutures are preferable or continuous lock stitch is
employed. If sutures do not control the bleeding, vagina should be packed tightly with 5
yard gauze. This reduces oozing and prevents haematoma formation.

-> Vesicovaginal Fistula

Vesicovaginal fistula may occur at child birth, during surgery, as complication of cancer
or radiation therapy.
Management: 2 or 3 layer repair is performed followed by continuous bladder drainage
for 10 days. When damage is not recognized or repair is not possible, continuous bladder
drainage is done. If fistula persists, active treatment is delayed for 2-3 months.

-> Haematoma
A haematoma is a localized bleeding outside of blood vessels.
Puerperal haematoma in Vulva & Vagina:
i) Vulval: Bleeding is limited to vulval tissue.
ii) Vulvo-vaginal: Involves paravaginal tissue, vulva, perineum or ischiorectal fossa.
iii) Vaginal/Concealed: Confined to paravaginal tissue.
iv) Supravaginal/Subperitoneal/Intraligamentous: Bleeding occurs above the pelvic
fascia and is retro-peritoneal.

Most haematomas are small, beneath the skin causing pain and discolouration, but are
not significant. The blood will be absorbed spontaneously.

Rupture of vessels under the vaginal mucosa is serious as submucosal tissue is loose.
Many haematomas contain already ½ litre of blood at the point of diagnosis.
In case of large amount of blood loss, there is pallor, tachycardia, hypotension, shock;
sometimes extreme shock leading to death.
 Wondershare
PDFelement

-> Rupture of Uterus / Uterine Rupture

Rupture of uterus is rare but dangerous complication and one of the most serious
accidents that can complicate labour. It may also occur during pregnancy.
Rupture of uterus may be spontaneous or traumatic.

 Uterine Rupture during pregnancy:

1) Spontaneous: Common. It occurs during last weeks of pregnancy due to
weakening of uterine wall by previous operation (myomectomy, classical CS)
or old perforation during MTP.

2) Traumatic: Rare. It occurs in the event of a crushing injury or blow on the

abdomen.

 Uterine Rupture during labour:

1) Spontaneous:
- Overstretching of lower uterine segment in obstructed labour.
- Uterine defects such as uterine wall weakening due to CS, myomectomy
scars, developmental anomaly or resistance to dilatation.
- Multiparity
- Injudicious use of oxytocics during labour.

2) Traumatic:
- Obstetric intervention in the event of uterine scar from a previous
operation.
- Internal version
- Breech extraction
- Difficult destructive operation

 Types of Uterine Rupture:

1) Incomplete:
- Rupture in lateral wall of uterus which is not covered by peritoneum.
- Over distension and haemorrhagic disruption of uterine wall.
- Traumatic uterine ruptures are usually incomplete.
- In incomplete uterine ruptures, only parts of the content escape.

2) Complete:
- All coats including the peritoneum are torn.
- Spontaneous uterine ruptures are usually complete.
- Usually followed by escape of contens into the peritoneal cavity.
- The empty uterus retracts firmly and severe haemorrhage will not occur
unless vessels are torn.

 Symptoms:
Symptoms of uterine rupture vary greatly from severe pain and shock, evidence of
profuce intraperitoneal haemorrhage to simple discomfort and slight disturbance.
 Wondershare
PDFelement

-> Inversion of Uterus / Uterine Inversion

Inversion of uterus is a grave postpartum complication. Prompt diagnosis and treatment
is vital to reduce the high maternal mortality and morbity rate.

 Classification:
A) Based on duration: - 3
1) Acute: Very rare but lethal. Diagnosed within 24 hours of delivery.
2) Sub-acute: Diagnosed after 25 hors but before completion of 4 weeks after
delivery.
3) Chronic: Diagnosed after completion of 4 weeks after delivery.

B) Based on extent of inverted uterine wall : - 4

1) First-degree: Corpus extends up to the cervix.
2) Second-degree: Corpus protrudes through the cervical ring into vagina but
not to the perineum.
3) Third-degree: Inverted fundus extends up to the perineum.
4) Fourth-degree / Total: Vaginal wall is also inverted along with the uterus.

 Cause:
- Mismanagement of 3rd stage of labour.
- Excessive cord traction or credes fundal pressure.
- Short cord, fundal inversion of placenta, morbid adherent placenta, fundal fibroid
- Precipitate labour
- Postpartum uterine atony
- Weak uterine musculature

 Signs & Symptoms:

The cardinal features of puerperal inversion of uterus are haemorrhage, shock and
pain. Per abdomen, the fundus is not felt, normal contour is lost, cup-like
depression is seen at the fundus.
Associated symptoms: Urine retention, dysuria, blood stained discharge, bearing
down pain

 Diagnosis:
- Signs & Symptoms
- USG
- Longitudnal scan
 Wondershare
PDFelement

 Postpartum Haemorrhage (PPH)

(Prasavottara Raktasrava)

Any amount of bleeding from or into the genital tract following birth of the baby up to
the end of the puerperium, which adversely affects the general condition of the patient
evidenced by rise in pulse rate and falling blood pressure is called postpartum
haemorrhage.

The amount of blood loss in excess of 500 ml following birth of the baby (WHO).

The average blood loss following vaginal delivery, caesarean delivery and caesarean
hysterectomy is 500mL, 1000 mL and 1500 mL respectively.
Depending upon the amount of blood loss, PPH may be:
- Minor (< 1L)
- Major (> 1L)
- Severe (> 2L)

 Incidence: 4-6%

 Classification
1) Primary Postpartum Haemorrhage (PPPH): When there is excessive bleeding
(> 500 ml) from the genital tract within 24 hours after delivery.
a) Third stage haemorrhage - Bleeding occurs before expulsion of placenta.
b) True postpartum haemorrhage - Bleeding occurs subsequent to expulsion
of placenta (majority).

2) Secondary Postpartum Haemorrhage (SPPH): When there is excessive

bleeding after 24 hours but within 6 weeks after delivery.

Primary Postpartum Haemorrhage:

 Cause:
1) Uterine atony: PPH is controlled by contraction and retraction of myometrial
fibres; failure of this mechanism results in disordered myometrial function
called uterine atony.

2) Trauma & laceration to the genital tract: Perineal tear, Vaginal tear, Cervical
tear, Haematoma, Uterine rupture, etc.

3) Retained products of conception: Placenta, Clots, Uterine fibroids

4) Coagulopathy: Any bleeding disorder such as Hypofibrinogenaemia

 Wondershare
PDFelement

 Diagnosis:
PPH is usually external. If there is concealed PPH, it is confirmed by squeezing the
uterus firmly and the blood is forced out with a gush.

 Prevention:
- Correct management of all stages of labour
- Placenta delivered by modified Brandt Andrews’ technique
- Hospital delivery

 Management:
a) Third stage haemorrhage
- Manipulation of uterus per abdomen; at first sign of unusual haemorrhage, the
uterus is grasped between fingers and thumb and massaged until it feels hard.
- Ergometrine 0.5 mg IV
- Catheterize if full blader
- Placenta delivered by modified Brandt Andrews’ technique
- If it is not delivered, manually removal under general anaesthesia (GA).
- If uterus does not retract, IV drip (10-20 units oxytocin).
- Bimanual compression may be needed.

b) True PPH
- Exploration of uterine cavity under GA; retained placenta bits are removed.
- Thorough examination of perineum, vagina, cervix for detection of lacerations.
- Bilateral ligation of internal iliac arteries or hysterectomy.
- If present, coagulation defects should be managed.
- Resuscitation: IV fluids, plasma expanders, blood transfusion

Secondary Postpartum Haemorrhage:

 Cause: Delayed involution because of infection and retained bits of placenta are
common causes of SPPH.

 Investigation: USG to rule out retained bits of placenta, Exploration of uterus

under GA and curettage, taking care not to traumatize the placental site.
 Wondershare
PDFelement

 Retention of Placenta / Retained Placenta

Retained placenta is a condition in which all or part of the placenta or membranes
remain in the uterus during the third stage of labour.
Retained placenta is generally defined as a placenta that has not undergone placental
expulsion within 30 minutes after delivery.
There are three phases involved in the normal expulsion of placenta:
(1) Separation through the spongy layer of the decidua,
(2) Descent into the lower segment and vagina,
(3) Finally its expulsion to outside.
Interference in any of these physiological processes, results in placental retention.

 Causes:
1) The placenta is detached completely, but is not expelled due to uterine
inertia or formation of contraction ring (hour glass contraction).
2) The placenta does not detach -> Adherent placenta:
a) Simple adhesion:
Placenta remains in union with the uterine wall although its
attachments are not abnormal. The cause for detachment is
inadequate uterine contraction and retraction. Usually, the whole
placenta is attached. If a part of it is detached or if there are attempt to
expess, it may lead to haemorrhage.

b) Morbid adhesion:
Placental attachmentis abnormal or pathological. There is no line of
cleavage between placenta and uterine wall. It is a rare condition.
- Placenta accreta = Chorionic villi invade up to myometrium.
- Placenta increta = Chroionic villi invade the myiometirum but not
beyond.
- Placenta percreta = Chorionic villi penetrate the whole uterine wall to
the serosal layer.

 Management:
- Manual removal of placenta under GA. Judicious use of halothane so that it
relaxes the constriction ring without producing uterine atony.
- Once the patient is comfortable, she should be appropriately positioned in
lithotomy. A conical drape, preferably one that is graduated and marked to allow
for quantitative blood loss, should be placed under the patient’s buttocks. The
operator should make every attempt to wear gown and gloves and maintain
sterility, both for personal and for patient protection. The patient’s bladder should
be drained. The provider should then use one hand to follow the umbilical cord
through the vagina and cervix until the placenta is palpated. If the placenta is
separated but not expelled, such as in the case of uterine atony, the tissue can be
firmly grasped and brought through the cervix. Uterotonic medications, such as
oxytocin, methylergonovine, carboprost, or other prostaglandins, should be given
to facilitate contraction once the placenta is removed.
 Wondershare
PDFelement

 Amniotic Fluid Embolism (AFE)

Amniotic fluid embolism is a rare but serious condition that occurs when amniotic fluid
or foetal material, such as foetal cells, enters the mother's bloodstream. Amniotic fluid
embolism is most likely to occur during delivery or in the immediate postpartum period.

 Causes & Pathophysiology:

Amniotic fluid embolism occurs when amniotic fluid or foetal material enters the
mother's bloodstream. A likely cause is a breakdown in the placental barrier, for
example due to trauma.
When this breakdown happens, the immune system responds by releasing
products that cause an inflammatory reaction, which activates abnormal clotting
in the mother's lungs and blood vessels. This can result in a serious blood-clotting
disorder known as disseminated intravascular coagulation.
However, amniotic fluid embolisms are rare and it is likely that some amniotic fluid
enters the mother's bloodstream without causing problems.

 Risk factors:
- Advanced maternal age
- Placenta preiva, abrputio placentae
- Pre-eclampsia, Polyhydramnios
- Medically induced labuor, Operative delivery

 Symptoms:
Amniotic fluid embolism might develop suddenly and rapidly.
- Shortness of breath, Excess fluid in the lungs (pulmonary edema)
- Low blood pressure, Incrased heart rate, irregular heart rate, Cardiovascular
collapse, Disseminated intravascular coagulopathy
- Vaginal bleeding, Chills, Seizures, Loss of consciousness
- Altered mental status, such as anxiety or a sense of doom
- Foetal distress

 Complications:
- Foetal brain injury
- Infant death
- Maternal death (AFE has a high mortality rate)

 Treatment:
AFE requires rapid treatment to address low blood oxygen and low blood
pressure. Emergency treatments might include:
- Catheter placement (arterial or venous)
- IV hydrocortisone, IV aminophylline
- Correction of acid base balance
- Oxygenation
- Blood transfusion
- Emergency CS if AFE occurs before delivery
 Wondershare
PDFelement

CHAPTER iiI: sutika vijnana

 Paribhasha & Paryaya

 Paribhasha:
- A woman is called as Sutika after being relieved of Garbha and Apara.
- A woman who has delivered recently and placenta has been expulsed is known
as Sutika.

 Paryaya:
Jatapatya, Prajata, Prasuta, Prasutika, Prasutaya, Suta, Sutaka, Navaprasuta,
Sadyaprasuta

 Sutika Kala
- Acharya Sushruta mentioned that after following the restricted Ahara and Vihara for
about 6 weeks, the woman is no longer termed as Sutika.

- Acharya Vagbhata mentioned that after about 6 weeks or until the re-commencement
of menstruation, the woman is relieved of the restricted Ahara and Vihara, and is no
longer termed as Sutika.

- Acharya Kashyapa mentioned that after about 6 weeks or until the re-commencement
of menstruation, the woman is no longer termed as Sutika. The restricted Ahara and
Vihara may be given up after 4 months.

-> Just as the Ahararasa in Garbhini nourishes Garbha, Matra and Stana, likewise after
delivery, the Ahararasa reaches the Stana, forming Stanya as Upadhatu, and the
remaining Rasa Dhatu is circulated through the whole body, including towards Yoni,
where it accumulates and forms Artava as Upadhatu, which will again be discharged
periodically.
 Wondershare
PDFelement

 Sutika Paricharya
(Management of Puerperal Woman)

 According to Acharya Kashyapa:

- Sutika should wear ornaments with Rakshoghna karma to prevent affliction of
Graha.
- Immediately after delivery, the woman must be encouraged and ensured by
cheerful attenders and is made to lie in hump back position.
- Her back is rubbed, abdomen and flanks are pressed to remove Vayu and
residual Doshas.
- The abdomen and flanks are wrapped with clean cloth to reduce size of the
abdomen and alleviate Vata.
- Sutika is advised to sit on a leather bag filled with warm Bala Taila and Svedana is
done by Krishara made of Priyangu. After Svedana, Sutika can take bath with warm
water and should rest.
- Dhupana is done with Ghrita, Kustha, Guggulu & Aguru.
- Manda is given for 3-5 days in accordance to Agni and Bala of Sutika, followed by
Satmya & Pathya Ahara and Sneha Dravya.
- After digestion of Sneha, Yavagu is prepared with Pippali & Nagara, without
Lavana and only little quantity of Sneha Dravya; it is given for 3 days.
- Then Yavagu is prepared with the same Dravya including sufficient Lavana &
Sneha as well; it is given for 6-7 days.
- Kulattha Yusha prepared with Sneha, Lavana, Amla and Mamsa Rasa should be
taken with Kushmanda, Mulika, Eravaruka, etc. vegetables fried in Ghrita.
- After delivery, till one month, Sutika should be free from Alasya and indulge in
Snehana, Svedana and Parisheka with warm water.
- Taking into consideration all the family traditions and culture, Ahara and Vihara
should be modified with respect to Desha & Kala.

 Benefits of Sutika Paricharya:

A Sutika who is emaciated due to growth and development of Garbha, and weak
due to expulsion of Kleda, Rakta & Asthira Dhatu, will regain the lost nourishment,
health, etc. by following Sutika Paricharya.
 Wondershare
PDFelement

 Normal Puerperium
 Definition:
Puerperium includes the 6 weeks following delivery during which the anatomical
and physiological changes of pregnancy regress.

 Changes during Puerperium:

▪ Temperature: Normal but, a reactionary rise may occur after difficult labour. It
does not exceed 38°C and drops within 24 hours. A slight rise may occur at the 3rd
day due to engorgement of the breasts.

▪ Pulse: Normal but may rise if there is haemorrhage or infection.

▪ After pains: Painful uterine contractions occur in early puerperium increasing

with suckling due to oxytocin release. If intolerable use analgesics.

▪ Breasts: Colostrum is secreted in the first 3 days.

With the establishment of milk secretion at the 3rd to 4th day, the breasts become
engorged, larger, painful, tender while suckling relieves the discomfort.
Suckling stimulates prolactin secretion, which causes milk production and oxytocin
release, which stimulates milk ejection.

▪ Urine: Diuresis by the 2nd - 4th day, lasting for 3-4 days.
Retention of urine may occur due to:
- Atony of the bladder
- Laxity of the abdomen
- Recumbence
- Reflex inhibition if the perineum is sutured.
- Compression of the urethra by vulval oedema or haematoma

▪ Bowel: Tendency to constipation due to:

- Atony of the intestine, Laxity of abdomen and perineum
- Anorexia, Loss of fluids

▪ Loss of weight: due to:

- Evacuation of the uterine contents
- More fluid loss through urine and sweat

▪ Blood: Increased coagulation of the blood continues during the first two weeks in
spite of significant decrease in a number of coagulation factors.

▪ Haemoglobin concentration: tends to fall in the first 2-3 days.

▪ Menstruation: is regained by the 6th – 8th week after delivery, but in lactating
women a variable period of amenorrhoea may be present.
 Wondershare
PDFelement

▪ The uterus is involuted as follow:

Structure:
i) Autolysis of the excess muscle fibres.
ii) The blood vessels are obliterated by thrombosis and become degenerated
while its remnants are transformed into elastic tissues.
iii) The decidua, except the basal layer, is separated.

Weight: After delivery the uterine weight is 1000 gm. By the end of 6 weeks it is 50
gm.
Size: After delivery the length of the uterus is 20 cm and felt at the level of
umbilicus. After one week it is midway between umbilicus and symphysis pubis.
After 2 weeks it is at the level of symphysis. By the end of the 6th week it is 7.5 cm
long.
Uterine ligaments: are involuted and subinvolution predisposes to prolapse and
retroversion.

▪ Lochia:
It is the genital tract discharge in the first 15 days of puerperium.
It is alkaline and composed of blood, decidual fragments, cervical mucus, vaginal
transudate and bacteria.
Lochia rubra (red): consists mainly of blood and decidua. It lasts for 5 days.
Lochia serosa (pale): due to relative decrease in RBCs and predominance of
leukocytes. It lasts for 5 days.
Lochia alba (white): consists mainly of leukocytes and mucus. It lasts for 5 days.
Persistence of red lochia means sub-involution.
Offensive lochia means infection.
In severe infection with septicaemia, lochia is scanty and not offensive.

▪ Cervix: is closed by the end of the first week.

▪ Vagina: Vaginal rugae appear in the 3rd week.

▪ Vulva: Its gaping disappears by the end of puerperium.

Perineum: regains its tone by the end of puerperium while persistence of its laxity
predisposes to prolapse.
 Wondershare
PDFelement

 Management of the Puerperium:

To restore health of the woman, to prevent infections, to promote lactation.

▪ Rest and exercises:

- Rest in bed for 2 days is advised after uncomplicated vaginal delivery and for a
longer few days in complicated or operative delivery.
- Semi-sitting position encourages drainage of lochia, 2 hours in prone position
daily to encourage anteversion of the uterus.
- Movement in and outside the bed and breathing exercises are advised during this
period to minimize the risk of deep venous thrombosis (DVT).
- Pelvic floor exercise is started in the 3rd day if there is no perineal wound by
alternating contraction and relaxation of the pelvic floor muscles. Abdominal
exercises are done later on.
These exercises have the following advantages:
Diminish respiratory and vascular complications.
Minimize future prolapse and stress incontinence.
Give a better cosmetic appearance later on.

▪ Local asepsis:
The vulva and perineum are washed with antiseptic lotion from front backwards
after each micturition and defecation and a sterile vulval pad is applied.
If there are perineal stitches add local antibiotic.

▪ Diet:
Rich in proteins, vitamins, minerals and fluids. High fibre-diet with plenty of fruits
and vegetables. Fatty food should be restricted.

▪ Care of the bowel:

Constipation is prevented by plenty of green vegetables and fruits, sufficient fluids
and local glycerin suppositories if needed.

▪ Care of the bladder:

Patient is encouraged to urinate frequently. If there is retention, a catheter is
applied under aseptic conditions.

▪ Care of the breasts:

Wash the nipple and areola with warm water and soap before each feeds

▪ Observations:
Mother: Pulse, temperature, breasts, lochia and involution of the uterus.
Foetus: Jaundice and umbilical stump.
 Wondershare
PDFelement

Sutika roga

Sutika Roga are puerperal disorders. They are Kricchrasadhya (difficult to cure) or Asadhya
(incurable) as the woman has gone through Dhatu Kshaya during Garbhavriddhi, Agni & Bala
are in Kshaya-avastha, and she has lost Kleda & Rakta during labour.
Among all Sutika Roga, Jvara is the most difficult to cure.

 Number of Sutika Roga

Acharya Kashyapa has mentioned 64 Sutika Roga in Sutika Upakramaniya Adhyaya of
Kheelasthana.
He has also mentioned 35 Sutika Roga in Dusprajata Chikitsa Adhyaya of Chikitsasthana.
25 of these diseases are found among the 64 mentioned in Sutika Upakramaniya
Adhyaya, and 10 are new.
So, in general, 74 different Sutika Roga have been described.

Sutika Roga in Sutika Upakramaniya Adhyaya: - 64

Yonibhrista, Yonikshata, Yonibhedana, Mutrasanga, Shotha, Yonisrava, Prasupta,
Yonivedana, Parshvashula, Pristashula, Katishula, Hritshula, Visuchika, Pleeharoga,
Mahodara, Shakavata, Angmarda, Bhukshepa, Hanustambha, Manyastambha,
Apatanaka, Makkalla, Vidradhi, Shopha, Pralapa, Unmada, Kamala, Durbalata, Bhrama,
Krishata, Bhaktadvesha, Avipaka, Jvara, Atisara, Visarpa, Chardi, Trishna, Pravahika,
Hikka, Shvasa, Kasa, Pandu, Raktagulma, Anaha, Adhmana, Varchograha, Mutragraha,
Mukharoga, Akshiroga, Pratishyaya, Galagraha, Rajayakshma, Ardita, Kampa, Karnasrava,
Prajagara, Ushnavata, Grahabadha, Stanaroga, Rohini, Vatasthila, Vatagulma, Raktapitta,
Vicharchika

Sutika Roga in Dusprajata Chikitsa Adhyaya: - 35

Yonibheda, Pristhabheda, Katibheda, Shakavata, Asrigdara, Vatasthila, Vatagulma,
Hritshula, Pravahika, Purisharodha, Mutrarodha, Adhmana, Udarashula, Yonishotha,
Yonidosha, Yonishula, Kampa, Chardi, Moha, Kamala, Manyasambha, Hanugraha, Jvara,
Atisara, Visarpa, Dadru, Pama, Vicharchika, Kitibha, Visphota, Ardha Shiroruja, Hridroga,
Pleehodara, Shvayathu
 Wondershare
PDFelement

 Samanya Nidana
- Going out during night, terror/horror, falling down, jealousy, grief, fear, anger,
suppression of natural urges, day sleep, eating despite of indigestion or before digestion
of previous meal, etc. are the factors responsible for Sutika Roga.
- Mithyachara (Asatmya / Apathya Ahara & Vihara) is the main causative factor for
Sutika Roga.

 Samanya Chikitsa
- Nidana Parivarjana (Chakrapani)
- Vatahara Chikitsa (Bhavaprakasha)
- Abhyanga, Parisheka, Avagaha, Annapana with Dravya which are Bhutahara, Jeevaniya,
Brimhaniya, Madhura & Vatahara. (Charaka)
- Snehapana by considering Desha, Kala & Vyadhi. (Sushruta)
- Snehana & Svedana to suppress Vayu. Yavagu with Deepaniya Dravya. (Kashyapa)
- Jeerakadi Arista, Sutikadashamula Kashaya & Taila, Dhatakyadi Taila, Sutikadi Rasa,
Sutikaghna Rasa, Sutikahara Rasa, Sutikantaka Rasa, Lakshminarayana Rasa

 Shodhana Karma in Sutika

With the expulsion of Rakta from Garbhashaya, also Doshas are expelled. Hence,
Vamana, Virechana, Basti & Nasya should generally not be performed in Sutika as Doshas
are already less.
In some Sutika Roga, mild form of Shodhana Karma may be performed in accordance to
the strength of Sutika and involved Doshas.

 Pathya in Sutika Roga

- Langhana, Mridu Svedana, Mardana, Abhyanga
- Katu, Tikshna, Ushna, Deepana, Pachana, Kapha-Vatahara Dravya
- Patola, Matulunga, Tambula, Dadima
- After 7 days, Brimhana can be done. After 12 days, Mamsa can be given. After 6 weeks,
Sutika can resort to routine Ahara & Vihara.
 Wondershare
PDFelement

 Sutika Jvara
Among all Sutika Roga, Jvara is the most troublesome.

 Bheda:
1) Nija - Vataja, Pittaja, Kaphaja, Sannipataja
2) Agantuja - Stanyottha, Grahottha

 Nidana:
- Vega sandharana, Ruksha Ahara & Vihara, Vyayama, Atyasrikkshaya (excessive
bleeding / loss of Asrika), Shoka, Atyagni-santapa, Katu-Amla-Ushna Dravya,
Divasvapna, Guru-Abhishyandi Ahara, affliction of Graha, Ajeerna, difficult or
abnormal labour – these are the causes of six types of Sutika Jvara.

- Sutika Jvara will be Kricchrasadhya if Sutika indulges additionally in Maithuna,

Viruddhahara, Ratrijagarana, Papakarma, Bhaya, Lobha, Krodha, Isha, etc.

- Sheeta Dravya, Upavasa, Vyayama, Ahitashana, etc. will increase the strength of
Sutika Jvara.

 Lakshana:
1) Vataja
Vishamoshma (irregular temperature), Angamarda, Jrimbha, Romaharsha,
Kashayavirasa (astringent taste in mouth), Shita-dvesha, Ushna-kamata,
Dantaharsha, Pralapa, Shuskodgara, Prajagara (sleeplessness), Adhmana,
Angasankocha

2) Pittaja
Trishna, Daha, Pralapa, Vamathu, Katukasyata (pungent taste in mouth),
Peetasya Nakha-Danta-Akshi-Vit-Mutra, Kantha-shosha, Shita-abhilasha

3) Kaphaja
Ushna-abhikamata, Kasa, Shiroruja, Gatragaurava, Mandoshmata (low fever),
Pratishyaya, Shukla Mutra-Purisha, Nidra, Tandra, Himadvesha, Sthivana
(repeated spitting), Madhurasyata (sweet taste in mouth), Gatrasadana,
Annavidvesha

4) Sannipataja
Muhu-Shita Muhu-Daha (feeling cold and hot alternately), Muhurushma
(frequent rise and fall in temperature), Sama-Asama Agni (normal &
abnormal Agni)
- Kricchra Vit-Mutra-Vata, Vata sa-shula (due to Vayu)
- Daha, Trishna, Pralapa, Asthira Chitta due to Pitta
- Gurutva, Kanthasamrodha, Pratishita (shivering) due to Kapha.
 Wondershare
PDFelement

5) Stanyottha
Stanya reaching the Stanyavaha srotas produces Stambha, Trishna,
Hridayadrava, Kukshi-Parshva-Kati Shula, Angamarda, Shiroruja
Lakshana subside as soon as the breastmilk is drained.

6) Grahottha
Udvepaka (tremors), Vibhrama, Shrama, Kampa Hasta-Netranam, Haridra
Mukha-Netra
- Vataja Sutika Jvara Lakshana

 Samanya Chikitsa:
Svedana, Apatarpana, Pachana, Kashaya, Abhyanga, Ghrita to alleviate Doshas
methodically.

 Vishesha Chikitsa:
1) Vataja
- Svedana, Mamsa Rasa, Anulomika Kashaya, Laghu Ahara
- Vatahara taila for Abhyanga, Nasya, Basti, Snehapana

2) Pittaja
- Mardana with Kashaya, Tikta & Madhura Dravya
- Amla, Ushna, Katu Dravya should be avoided.
- Pradeha with Daru, Talisa, Ushira, Chandana
- Abhyanga with Taila processed with Madhuka & Tagara
- Asava prepared with Sharngistha, Maruva, Patha, Naktamala, Vatsaka,
Nimba, Aragvadha, Ushira
- Ghrita prepared with Patola, Guduchi, Rohini, Aragvadha, Chandana Kalka

3) Kaphaja
- Samsarjana karma, Aushadhapana, Ghrita, Abhyanga
- Madhura, Snigdha, Guru Ahara should be avoided.
- Lakshadi Taila for Abhyanga
- Kalyanaka & Dashamula Ghrita for Snehapana
- Virechana with Trivrita Kalka & Gomutra

4) Sannipataja
The most dominant Dosha should be treated first. If all three Doshas are
equally strong, Kapha should first be alleviated.

5) Stanyottha
Stanyashodhana -> Refer to Stanya Vijnana

6) Grahottha
Same as Vataja Sutika Jvara Chikitsa
 Wondershare
PDFelement

 Makkalla
Makkalla is a condition which is dominated by pain. Due to the vitiation of Vayu, there is
accumulation of blood in Sutika or Garbhini leading to pain in cardiac region, head and
Garbha. It has poor prognosis and can cause Rakta Vidradhi.

 Behda: - 2
1) Garbha-Avstha (During pregnancy)
2) Sutika-Avastha (During puerperium)

 Nidana:
- Accumulation of Rakta in Garbhashaya due to Vataprakopa
- Unpurified or accumulated Rakta after delivery
- Improper use of Aushadha (specifically Panchakola) to purify Rakta after delivery

 Lakshana:
- Formation of Granthi in Udara, around Nabhi, Parshva, Basti
- Shula in and around Nabhi, Basti, Udara, Ura, Pakvashaya
- Atopa, Adhmana, Mutra sanga

 Chikitsa:
- Yavakshara with Ghrita or Ushnodaka
- Trikatu, Trijata, Guda with Dhanyambu
- Pippalyadi Gana Churna with Suramanda
- Varunadi Kvatha with Panchakola Churna
- Shuddha Hingu with Ghrita
 Wondershare
PDFelement

 Abnormal Puerperium / Puerperal Disorders

 Puerperal Pyrexia
Puerperal Pyrexia is defined as temperature elevation of 38°C or more, on more
than two occasions at least 24 hours apart, after 24 hours postpartum.

Etiology:
Genital tract infection, Wound infections, Urinary tract infection, Puerperal
Mastitis, Thrombophlebitis, Pulmonary complications (e.g.: Pneumonia),
Meningitis

Clinical features:
- Mild endomyometritis - Mild temperature, 2-3 days postpartum, lower
abdominal discomfort and tenderness
- Severe endomyometritis - High temperature, abdominal pain & tenderness, sub-
involuted uterus, foul smelling vaginal discharge; may lead to pelvic abscess
- Puerperal sepsis

Management:
Prevention is important - observing aseptic precautions, limiting vaginal
examination, minimizing tissue trauma and blood loss during labour or surgery are
the best ways to minimize the chances of infection.
If there is evidence of retained products, evacuation is done after 24 hours by
antibiotic therapy.

 Wound Infection
It is commonly encountered by 4th post-partum day. There is persistent fever with
tender erythematous incision with drainage of blood or pus, gaping wound.
Obesity, diabetes, poor haemostasis, haematoma formation, etc. are risk factors.
Prophylactic antibiotics are usually advised.

 Urinary Tract Infection

Incomplete voiding of urine, urine retention contributes to the risk of UTI in
immediate postpartum period. Predisposing factors are asymptomatic bacteriuria
in pregnancy, prolonged labour, trauma following instrumental y, frequent
catheterization.
Symptoms: Fever with chills, malaise, suprapubic tenderness
Treatment: Antibiotic therapy with adequate fluid intake

 Thrombophlebitis
Unexplained spiky fever and pain on 4th or 5th postpartum day is the typical clinical
picture. It can lead to septic embolization and pulmonary abscess.
Heparin with broad spectrum of antibiotics is the main treatment.
 Wondershare
PDFelement

 Obstetric Paralysis
This is a transient condition due to the compression injury of the common
peroneal nerve as it passes around the head of fibula and is compressed against
the obstetric stirrups in prolonged use of lithotomy position during delivery.
There is impaired extension of the toes and foot, sensory loss on antero-lateral
aspect of shin and foot. Physiotherapy may be useful and most of the cases
resolve by 2-3 months.

 Postpartum Haemorrhage (PPH) -> Refer to CHAPTER II: Prasava Vyapad

 Postpartum Oedema (Sutika Shotha)

Postpartum oedema, or postpartum swelling, is caused by an excess amount of
fluid remaining in the body tissue after childbirth. Swollen extremities (hands,
feet, and ankles) and weight gain are the main symptoms of oedema. Swelling can
lead to the skin looking stretched and inflamed, and will sometimes cause the
outer layer of the skin to look puffy or shiny.

Mild oedema is extremely common - most women experience some level of

swelling after giving birth. The body naturally prepares for childbirth by retaining
water to help body tissue adapt to the baby’s growth and naturally eliminates this
fluid post-childbirth.

The postpartum swelling in legs, feet, and hands will naturally go down within the
first week after pregnancy. During this time, the body is flushing excess water
from the tissue in the swollen regions. This process takes a different amount of
time for everyone but can be sped up by eating a lot of healthy foods, staying
hydrated, and allowing the body to rest and recover.

Postpartum oedema becomes an issue when symptoms such as severe swelling

and/or pain and discomfort occur. Intense pain in the legs or frequent headaches
can be a sign of high blood pressure. If the swelling is located in just one area or is
only on one side of the body, this can be a sign of a blood clot.
 Wondershare
PDFelement

 Postpartum Psychiatric Problems

The 3 common manifestations are:
i) Postpartum blues
ii) Postpartum depression
iii) Postpartum psychosis

i) Postpartum blues:
It is seen during 3rd-5th postpartum day. The patient presents with symptoms of
lethargy, anxiety, headache, poor concentration, irritability, and unexplained
crying spells. It is a self-limiting condition requiring assurance and emotional
support.

ii) Postpartum depression:

It is seen within 6 months of child birth when all the excitement and attention
fades away and the patient confronts with the harsh realities and demands of an
infant day and night. Diagnosing criteria is at least five of the following symptoms
for at least two weeks – Depressed mood, significant change in weight, insomnia /
hypersomnia, psychomotor agitation or retardation, feelings of guilt, impaired
concentration and recurrent suicidal thoughts.
Management includes counselling, family support, domestic help, short term
tranquilizers and psychiatric help.

iii) Postpartum psychosis:

Women with an underlying psychiatric disorder (especially schizophrenia and
bipolar disorder) are more prone to develop postpartum psychosis.
They present with mental disturbances like delusions, hallucinations or mania.
Puerperal infections, exhaustion, Sheehan’s syndrome and drug reactions may
precipitate the crisis.
 Wondershare
PDFelement

 Emergency Care in Obstetrics

Basic emergency obstetric and newborn care is essential to reduce maternal and neonatal
complications and even to prevent death.
This care, which can be provided with skilled staff in health centres, large or small, includes
the capabilities for:
- Administering antibiotics, uterotonic drugs (oxytocin) and anticonvulsants (magnesium
sulphate)
- Manual removal of the placenta
- Removal of retained products following miscarriage or abortion
- Assisted vaginal delivery, preferably with vacuum extractor
- Basic neonatal resuscitation care

Comprehensive emergency obstetric and newborn care, typically delivered in hospitals,

includes all the basic functions above, plus capabilities for:
- Performing Caesarean sections
- Safe blood transfusion
- Provision of care to sick and low-birth weight newborns, including resuscitation

Coverage:
Guidelines jointly issued in 1997 by the World Health Organization, the UN Children’s Fund
and UNFPA recommended that for every 500,000 people there should be four facilities
offering basic care and one facility offering comprehensive essential obstetric care.
To manage obstetric complications, facilities must have multiple skilled attendants covering
24 hours a day, seven days a week, assisted by trained support staff.
To manage complications requiring surgery, facilities must have a functional operating
theatre, more support staff, and must be able to administer safe blood transfusions and
anaesthesia.

Reducing life-threatening delays:

Timing is critical in preventing maternal death and disability: Although post-partum
hemorrhage can kill a woman in less than two hours, for most other complications, a woman
has between six and 12 hours or more to get life-saving emergency care. Similarly, most
perinatal deaths occur around delivery or in the first 48 hours afterward.
A ‘three delays’ model helps identify the points at which delays can occur in the
management of obstetric complications. Understanding these delays can help health officials
design programs to address these delays.
 Wondershare
PDFelement

The first delay often happens when a woman, or her family, is put off seeking care. The
second delay can occur when she tries to reach appropriate care.
Both of these delays relate to the issue of access to care, involving factors such as family and
community beliefs, awareness, affordability of care, availability of transport and distance to
the care. Improved awareness in the community and use of new communications
technologies – including mobile phones – can address the first delay. Improved transport
services and reduced transport costs can effectively address the second delay.
The third delay is delay in receiving care at health facilities. This involves factors within the
health facility, including organization, quality of care, and availability of staff and equipment.
Addressing these situations is an essential condition for ensuring that obstetric emergency
situations are efficiently managed.
Unless all three delays are addressed, no safe motherhood program can succeed.
 Wondershare
PDFelement

Stanya vijnana

"िन्यं क्षीरं रसस्य उपिािुः ।"

Stanya is the breastmilk and Upadhatu of Rasa Dhatu.

 Paryaya:
- Paya / Manusha Paya)
- Ksheera / Nari-Ksheera / Stree-Ksheera)
- Dugdha
- Piyusha (Colostrum)
- Amrita

 Panchamahabhoota: Jala predominant

 Moolasthana: Stana

 Srota: Stanyavaha Srota

 Pramana: 2 Anjali

 Nirmana:
- According to A. Sushruta, during pregnancy, Artava (menstrual fluid is
obstructed) and goes downwards to form Apara (placenta), and upwards to form
Stanya.

- According to A. Charaka, Stanya is formed as a byproduct of Rasa Dhatu during its

metabolism. Rasa Dhatu is circulated all over the body from Hridaya by Vyana-
Vayu. When Rasa Dhatu enters Stana, Madhura Rasa of Rasa Dhatu forms Stanya.

- According to A. Vagbhata, Artavavaha Srota constrict immediately after delivery

due to excessive Vata, which causes opening of Stanyavaha Srota and Stanyavaha
Dhamani.

 Nirmana Kala:
- Garbhavastha (during pregnancy)
- Prasuti kala (after delivery)
 Wondershare
PDFelement

 Stanyapravritti:
The causes for Stanyapravritti (milk ejection) are:
- अपत्यसम्स्पशभ Physical contact with the baby
- दशभन Sight of the baby
- स्मरण Thought of the baby
- ग्रहण Holding the baby

Due to these factors, Stanya gets ejected from the breasts of a woman in the
same way as Shukra gets ejaculated from the body of a men.
Constant affection towards the baby is said to be the main reason for the
maintenance of lactation.

 Stanyapana Vidhi:
A woman is said to breast-feed the baby in the following manner:

- When she is having milk in sufficient quantity and proper quality

- Having a pleasant mind
- After taking bath and anointing herself
- Washing the breasts properly
- Wearing white dress
- In sitting posture facing eastern direction
- After expressing out a little milk
- Should feed from the right breast first in the first feeding session

If before feeding a little milk is not expressed out, the breasts will become tense
and over accumulated with milk. If the baby is fed on such breasts, breast milk
may flow out in a gush and enter other passages (trachea) leading to Kasa, Shvasa,
Jvara and Chardi.

 Stana Sampat:
Stana sampat are the breasts which have excellent qualities. Such breasts are also
considered to be a factor for successful breast-feeding. Stana sampat are the
breasts which do not have any of th following characteristics:

Characteristics of breasts Effects on baby

Too highly situated than Deformity of teeth & eyes,
normal position unpleasant appearance of face.
Too elongated Obstruction to expiration and may
cause death
Bulky Neck rigidity
 Wondershare
PDFelement

 Stanya Sampat & Pariksha & Guna:

The qualities of pure / normal breast milk are assessed based on its physical
features, qualities and its effect on the child.

1) Lakshana:
- When dropped in water, Stanya mixes uniformly.
- Colour = White (like Shankha)
- Neither frothy or sticky, does not form any threads
- Cold to touch
- Clear without any sedimentation
- No vitiation of Dosha
- Normal colour, smell, taste & touch

2) Prabhava:
- Normal growth & development are observed in the baby.
- Arogya
- Bala
- Susattva
- Agni vardhana
- Srotovishuddhi
- Vrishya
- Tridoshashamana
- Rupavan

3) Guna:
"नायभिु मिु रं िन्यं कषायानुरसं तहमम् ।
नस्याश्चयोिनयोः पथ्यं जीवनं लघु दीपनम् ॥ (सु - सू - ४५ / ५७-५८)
According to Acharya Sushruta, Nari-Ksheera is the breastmilk which is:
- Madhura, Kashaya (Anurasa), Hima, Laghu
- Pathya, Jeevana, Deepana
- Good for Nasya-Karma & Netra Tarpana.

"जीवनं बृंहणं सात्म्यं स्नेहनं मानुषं पयः ।

नावनं रक्ततपत्ते च िपभणं चातक्षशूतलनाम् ॥" (च - सू - २७ / २२४)
According to Acharya Charaka, Manusha Paya is:
- Jeevana, Brimhana, Satmya, Snehana
- Good for Navana-Karma in case of Raktapitta.
- Good for Tarpana-Karma in case of Akshishoola.
 Wondershare
PDFelement

 Stanyadosha
Stanya is the ideal food for providing nutritional and psychological satisfaction for an
infant. Therefore, if there is any abnormality in the breastmilk (Stanyadosha), it may
cause serious complications for the child.

 Vargikarana: -
1) Stanya Pramana Dosha
i. Stanya Kshaya
ii. Stanya Vriddhi

2) Stanya Guna Dosha / Stanya Dusti

i. Vataja
ii. Pittaja
iii. Kaphaja
iv. Dvandvaja
v. Sannipataja
vi. Abhigataja
 Panchaksheera Dosha
 Astaksheera Dosha
 Graha Dusta Ksheera
 Wondershare
PDFelement

a) Stanya Pramana Dosha

i. Stanya Kshaya (Decreased breastmilk)
 Nidana:
- Lack of affection towards the child
- Bhaya, Shoka, Krodha
- Rukshatva
- Pregnancy starts during lactation period
- Excessive Shodhana Chikitsa
- Svabhava Stanya Kshaya (natural less production of breastmilk)

 Lakshana:
- Looseness of breasts
- Decreased secretion of breastmilk

 Chikitsa:
- Stanyajanana & Vardhanopakrama

ii. Stanya Vriddhi (Increased breastmilk)

 Nidana:
- Excessive use of Shleshmala Dravya

 Lakshana:
- Engorgement of breasts
- Heaviness of breasts
- Excessive discharge of breastmilk

 Chikitsa:
- Nidana parivarjana
- Shamana
- Shodhana (esp. Vaman & Virechana)

b) Stanya Guna Dosha / Stanya Dusti (Vitiated breastmilk)

 Stanya Dusti Nidana:
- Viruddha Ahara, Asatmya Ahara, Atibhojana, Ajeerna
- Amla, Lavana, Katu, Kshara, Abhishyanda Ahara
- Mana santapa
- Bhaya, Shoka, Krodha
- Nidranasha
- Divasvapna
- Vega vidharana
- Avyayama
- Abhigataja Vrana
- Dhatu Kshaya
- Excessive use of Shali, Dugdha, Sharkara, Guda, Dadhi, Matsya, Mamsa, Madya
 Wondershare
PDFelement

i. Vataja Stanya Dusti (All Acharyas)

 Lakshana:
- Blackish-brown discolouration
- Tikta & Kashaya Anurasa or Anirdesha Rasa
- Vishada, Agandha, Ruksha, Drava, Phenila
- Does not nourish and satisfy the child.
- Induces Karshya and increases Vata in the child.
- Vataja Stanya mixed in water – Stanya floats, gets scattered and spreads
like an umbrella, blackish

ii. Pittaja Stanya Dusti (All Acharyas)

 Lakshana:
- Blackish, blue, yellow or coppery discolouration
- Tikta, Amla, Katu Anurasa
- Ushna
- Gandha: Like dead body or blood.
- Increases Pitta in the child.
- Pittaja Stanya mixed in water – Greenish, reddish or slightly blackish

iii. Kaphaja Stanya Dusti (All Acharyas)

 Lakshana:
- Ati-Shukla
- Ati-Madhura, Lavana Anurasa
- Gandha: Like Ghrita, Taila, Vasa or Majja
- Picchila, Sheeta
- Increases Kapha in the child, leading to excessive sleep, numbness,
swelling of face & eyes, vomiting.
- Kaphaja Stanya mixed in water – sinks to the ground

iv. Dvandvaja Stanya Dusti - VP, VK, PK (All Acharyas except Sushruta)

v. Sannipataja Stanya Dusti - VPK (All Acharyas except Sushruta)

vi. Abhigataja Stanya Dusti (Acharya Sushruta & Acharaya Madhavakara)

External injury to a breast feeding women leading to vitiation of Stanya and
showing Vataja Stanya Dusti Lakshana.
 Wondershare
PDFelement

 Panchaksheera Dosha (Acharaya Harita)

(1) Ghana (Thick)
(2) Alpa (Less)
(3) Ushna (Hot)
(4) Kshara (Alkaline)
(5) Amla (Sour)

 Astaksheera Dosha (Acharaya Charaka)

"वैरस्यं फेनसङ्घािो रौक्ष्यं चे त्यतनलात्मके तपत्ताद्वै वर्ण्भ दौगभन्ध्ये स्नेहपैस्तिल्यगौरवम् ॥
कफाद्भवति ... ॥" (च - तच - ३० / २३७-२३८)

Dosha Abnormality Effect on the child

01) Vairasya - Vata Foul taste Delay of growth & development

02) Phenasanghata - Vata Froth Svarakshaya, Mutra-Pureesha & Vata-apravritta,

Vataja Shirashoola, Pinasa

03) Raukshya - Vata Dryness Durbalya due to lack of nutrients

04) Vaivarnya - Pitta Discolouration Vaivarnya, Trishna, Atisveda, Atisara, Ushna,

No desire for Stanya

05) Vaigandhya - Pitta Foul smell Pandu, Kamala

06) Sneha - Kapha Unctousness Chardi, Ati-lala, Ati-nidra, Shrama, Shvasa, Kasa

07) Paishcchilya - Kapha Sliminess Ati-lala (excessive salivation), Mandatva,

Oedema of eyes & face

08) Gaurava - Kapha Heaviness Hridroga

 Graha Dusta Ksheera (Acharya Kashyapa)

Graha Dosha Lakshana
Shakuni Graha Katu & Tikta Rasa
Putana Graha Svadhu & Katu Rasa
Skanda & Shasti Triodsha Dusta Ksheera
 Wondershare
PDFelement

 Stanya Dusti Chikitsa:

Stanya Dusti should be managed by treating both mother and the affected child.
Medicines for the child are either administered directly or applied over the breast
of mother and the child is made to suck the breasts so that the medicine enters
with breastmilk.

o Shodhana
Depending on the predominance of Dosha in Stanya Dusti, Shodhana
should be planned for the mother.
- Vataja = Basti, Virechana
- Pittaja = Virechana
- Kaphaja = Vamana

Dravya for Shodhana:

- Basti = Trivrit, Bilva, Gokshura, Agnimantha, Vacha, Shatapuspa,
Yastimadhu, Sarshapa

- Virechana = Trivrit or Haritaki Churna, Triphala Kvatha, Haritaki Churna

with Madhu or Gomutra

- Vamana = Vacha, Yastimadhu, Triphala, Vatsaka, Sarshapa mixed with

Kvatha prepared from Nimba tvak, Patola patra and Saindhava Lavana

Shodhana is generally not indicated for the child. Only in case of Kapha
Dusta Stanya Pana, Sukha Vamana can be considered.
Sukha Vamana Dravya = Ghrita mixed with Saindhava Lavana & Pippali or
Saindhava Lavana & Yastimadhu
It should be administered on the lips of baby or applied on the breast of
mother to induce Sukha Vamana.

o Stanyashodhana, Stanyajanana & Vardhanopakrama

o Pathya:
- Ahara & Vihara opposite to qualities of aggravated Dosha.
- Yava, Godhuma, Shalo, Shastika, Mudga, Harenuka, Kulattha, Lashuna
 Wondershare
PDFelement

 Stanyashodhana
Stanyashodhana is the process of administration of medicines for the mother to purify
the breastmilk & enhance its quality.

 कषायपानैवभमनैतवरे कैः पथ्यर्ोजनैः ।

वाजीकरणतसद्धै श्च स्नेहैः क्षीरं तवशुध्यति ॥ (क - सू – १९ / ५)
Ksheera gets purified by drinking Kvatha, Vamana, Virechana, Pathya Ahara,
Vajeekarana & Snehana Dravya.

 Acharya Charaka has mentioned the following 10 Dravya in Stanyashodhana

Mahakashaya Varga in Sutra Sthana, Chapter 4:
Patha, Mahaushadha, Devadaru, Musta, Murva, Guduchi, Kutaja, Kiratatikta,
Katurohini, Sariva

 Acharya Kashyapa has given following recipes for Stanyashodhana:

- "तत्रफला सतत्रकटु का पाठा मिु रसा वचा ।
कोलचू णं त्वचो जम्स्वा दे वदारु च पेतषिम् ॥ ६ ॥
सषभपप्रसृिोस्तिश्रं पािव्यं क्षौद्रसंयुक्तम् ।
एिि् िन्यस्य दु ष्टस्य श्रेष्ठं शोिनमु च्यिे ॥ ७ ॥"
1 Kola (6 gm) Churna of Triphala, Trikatu, Patha, Madhurasa, Vacha, Tvak, Jambu,
Devadaru should be mixed with 1 Prasrista (96 gm) of Sarshapa Kvatha and drunk
along with Kshaudra. This is the best purifier of vitiated breastmilk.

- Churna of Pippali, Shringavera and Patola should be taken along with Yusha.

- Dhataki, Ela, Samanga, Maricha, Jambu tvak & Madhuka.

- Patha, Mahaushadha, Daru, Murva, Musta, Kutaja, Sariva, Arista, Katuka, Kairata,
Triphala, Vacha, Guduchi, Madhuka, Draksha, Dashamoola with Deepana &
Rakshoghna Dravya as well as Patoladi Varga are useful for preparing Kvatha to
purify Stanya.
Kvatha should be taken along with Madhu in Kaphaja Stanya Dusti. In other types,
Ghrita should be taken instead.

 Pathya during Stanyashodhana period:

- Masura, Shastika, Mudga, Kulattha, Shali, Ghrita, Go-Ksheera, Aja-Ksheera,
Saindhava Lavana

 Apathya during Stanyashodhana period:

- Mamsa, Guru & Snigdha Ahara, Divasvapna
 Wondershare
PDFelement

 Stanyajanana & Vardhanopakrama

Stanyajanana & Vardhanopakrama are measures to increase the quantity & quality of
breastmilk.

 Acharya Charaka has mentioned the following 10 Dravya in Stanyajanana

Mahakashaya Varga in Sutra Sthana, Chapter 4:
Ushira, Shali, Shastika, Ikshuvalika, Darbha, Kusha, Kasha, Gundra, Itkata, Katruna

 Acharya Kashyapa has mentioned the following measures to increase the quantity
of breastmilk in Sutra Sthana, Chapter 19:
- Nadika, Guda prepared with Hingu & Jati
- Ksheera, Mamsarasa, Madya
- Vajeekarana Dravya with Ksheera
- Ghrita, Taila
- Bastikarma

 Other measures which are Stanyavardhaka are:

- Shleshmala Dravya / Kaphavardhaka Ahara
- Shatavari, Ashvagandha, Musali, Brihati
- Sufficient rest, pleasant state of mind
- No worries, anger, sadness, fear

 Stanya-Abhave Dugdha Vyavastha

- If breast milk of mother or weat nurse is not available, the next suitable milk to
the infant is the milk of cow or goat.
- It is advised to process the milk of cow or goat with decoction of
Laghupanchamula or Sthira by adding sugar.
The processing of milk with these drugs changes the composition of the milk,
making it more nutritious, suitable for easy digestion and absorption.
 Wondershare
PDFelement

Breast milk

Human milk is exclusively suitable to an infant as it provides the complete nutrition for
the first 6 months of life.
In addition to the appropriate amounts of carbohydrate, fat and protein, breast milk
containts antibodies and lymphocytes from the mother that protect the baby from
infections.
The composition of breast milk varies from day to day, depending on food consumption
of the mother and environmental factors. It varies within a feeding, lactation and
between mothers and different populations.

To understand the properties of breast milk it can be divided into 3, based on the stages
of lactation.

1) Colostrum:
- The first breast fluid produced by mothers in the late stage of
pregnancy and just after delivery is called as colostrum.
- It is thin and yellowish in colour.
- It is produced in low quantities and only in the first few days
postpartum.
- It acts as a mild laxative which helps in expelling the meconium and
prevents the buid-up of bilirubin.

2) Transitional milk:
Transitional milk appears in the first 3-4 days after delivery. It is thin,
watery and tastes very sweet. Gradually, the quantity of breast milk
increases and the colour and compositions also change. The approximate
duration during which it can be transitional milk is from 5 days to 2
weeks. It has relatively lower protein conten compared to colostrum, but
contains more sugar and fat.
 Wondershare
PDFelement

3) Mature milk:
Mature milk is produced after the stage of transitional milk and
continues until termination of breast-feeding.
By approximately 4-6 weeks postpartum, milk is considered as fully
mature. It contains more fat, sugar and water soluble vitamins, but fever
proteins compared to colostrum.

 Fore & Hind milk:

In addition to the changes from colostrum to mature milk, variation exists
within one given breast-feeding session. The milk first ingested by the infant is
known as the fore milk. It has a lower fat content.
As the infant continues to be fed over the next several minutes, the fat content
increases. This milk is called the hind milk, which is said to help in satiety of the
infant.
 Wondershare
PDFelement

 Lactogenesis & Lactation

Lactogenesis is the initiation of breast milk production which includes a series of cellular
changes in which mammary epithelial cells are converted from non-secretory state to
secretory state.
The whole process is divided into 3 stages:

1) Stage I: Conversion of alveolar epithelial cells into lactocytes that secrete

colostrum. Approximately 100 ml will be available to the infant on 1st day
of postpartum.

2) Stage II: It is the onset of copious milk secretion, occurring between

32-96 hours postpartum.

3) Stage III: This stage signifies the maintenance of milk production.

- Physiology of Lactation:

Hormones involved in Lactogenesis are:

i) Prolactin Helps in synthesis; secreted by posterior pituitary gland
ii) Oxytocin Helps in ejection; secreted by anterior pituitary gland

Once initiated, the production of milk is also maintained by 2 other factors:

i) Regular empyting of the breasts at each feed by the infant.
ii) Sensory stimulus produced at the nipple by the act of suckling.
The sensory stimulus on reaching the hypothalamus, causes secretion of
prolactin and oxytocin from the pituitary gland. Secretion of milk happens due
to the effect of prolactin.
It is secreted during and after feeding to produce milk for the next feed.
Secretion of prolactin is more at night. It also suppresses ovulation.
 Wondershare
PDFelement

Oxytocin causes contraction of the involuntary muscle fibres of the mammary

gland and thus aids the flow of milk along the ducts to the nipple, and the
complete emptying of breasts.
This is called as ‘Let down’ reflex.
Oxytocin acts before or during feeding to maintain the flow of breast milk.

Milk ejection / Let down reflex:

- Presence of the infant or infants cry can induce let down without suckling.

- A sensation of rise of pressure in the breasts by milk experienced by the mother at

the beginning of sucking is called “draught” this is can also be produced by injection
of oxytocin.

- The milk ejection reflex is inhibited by factors such as pain, anxiety, breast
engorgement or adverse psychic condition (depression).

- The ejection reflex may be deficient for several days following initiation of milk
secretion and results in breast engorgement.

- Breast milk synthesis is approximately 500-800 ml / day. The actual volume of milk
secreted may be adjusted to the requirement of the infant. The rate of milk synthesis
is related to the degree of breast emptiness or fullness. A breast which is emptier,
produces faster new breast milk compared to an already fuller breast. However,
maternal stress and fatigue adversely affect the lactation process.
 Wondershare
PDFelement

 Lactation Failure / Inadequate Milk Production:

It may be due to infrequent suckling or due to endogenous suppression of
prolactin (ergot preparation, pyridoxin, diuretics or retained placental bits).
Pain, anxiety and insecurity may be hidden reasons.
Unrestricted feeding at short interval (2–3 hours) is helpful.

 Galactogogues: Drugs to improve milk production

- Metoclopramide (10 mg thrice daily) increases milk volume (60-100%) by
increasing prolactin levels.
- Sulpiride (dopamine antagonist), domperidone has also been found effective by
increasing prolactin levels.
- Intranasal oxytocin contracts myoepithelial cells and causes milk let down.

 Suppression of Lactation:
- It may be needed for women who cannot breastfeed for personal or medical
reasons.
- Lactation is suppressed when the baby is born dead or dies in the neonatal
period or if breastfeeding is contraindicated.
- Methods commonly used are:
(i) to stop breastfeeding,
(ii) to avoid pumping or milk expression,
(iii) to wear breast support,
(iv) ice packs to prevent engorgement,
(v) analgesics (aspirin) to relieve pain and
(vi) a tight compression bandage is applied for 2-3 days.

The natural inhibition of prolactin secretion will result in breast involution.

 Wondershare
PDFelement

 Specific feeding schedule

Adequate nutrition for the newborn child is fundamental for a healthy life. The
growth and development of an individual is directly proportional to the type of
nutrition he / she receives. The rate of growth and development is faster in an infant
until 6 months of age compared to any other period in life. Therfore, the source of
nutrition should be adequate both quantitatively and qualitatively while taking care
of digestion and absorption capability of the child.
The ideal source of nutrition for a newborn is breast milk.

- Exclusive breast-feeding (nothing other than colostrum and breast milk) is

recommended by WHO up to 6 months of age with continued breast-feeding along
with appropriate complementary foods up to 2 years of age or beyond.

- Recommendations of WHO & UNICEF:

i) Initiation of breast-feeding within the first hour of life. In case of caesarean
delivery, it may be after 4-5 hours.

ii) The infant should only receive colostrum and breast milk without any additional
food or drink (not even water). No other food or fluids should be given to the infant
below six months of age unless medically indicated.

iii) Breast-feeding on demand: The baby should be breast-fed as often as he / she

wants throughout day and night. This is called Demand feeding.

iv) No use of bottles, teats or pacifiers.

- Time schedule:
Demand feeding is the advisable schedule. The following should be considered as the
approximate time period:
One feed per 2-3 hours for first 24 hours
One feed per 3-4 hours by the end of one week
Night feeds are also necessary to avoid long intervals between feeds.

- Duration:
Initial feeding = 5-10 minutes at each breast
Gradually, the time on each breast should be increased so that the baby gets both,
fore milk and hind milk. Each breast should be fed alternatively.

- Quantity:
Average requirement of breast milk:
100 ml / kg / 24 hours by 3rd day
150 ml / kg / 24 hours by 10th day
 Wondershare
PDFelement

 Techniques of breast-feeding
Successful breast-feeding is dependent upon many factors related to position,
attachment of the baby to the breast, psychological status of the mother and
experience.

The guidelines for breast-feeding are as follows:

- Mother should wash her hand before feeding
- Wash breasts at least once a day
- Repeated washing of nipples are is to be avoided
- Both, mother and baby should be in a comfortable position

The attachment of the baby to the mother’s breast will be optimum in the above shown
positions and both, the mother and the baby will be comfortable.
Proper attachment to the breast is such that enough areola is inside the baby’s mouth so
that the baby can express the milk from the lactiferous sinuses with the tongue.
 Wondershare
PDFelement

Signs of correct attachment to the breast:

- Baby’s mouth will be wide open with the tongue over the lower gums.

- There will be more of the areola visible above than below the mouth.
- Baby’s chin is touching the breast firmly, the lower lip will be rolled down and the nose will
be free.
- Baby will take slow, deep sucks with occasional pauses.
- No pain will be felt by the mother.

Burping: It is the technique by which the baby is held upright with its chest or abdomen
against the shoulder of the mother / care taker and the back is gently patted until the baby
belches out excessive air. This is done after feeding to push the air out of the stomach of the
baby which is swallowed during the act of suckling.

 Advantages of breast-feeding
1) For the mother
- Convenient as there is no need of any special preparation to feed
- Cheaper than artificial milk
- Faster maternal recovery and involution of the uterus
- Regain figure faster due to utilization of fat deposited during pregnancy
- Less risk of breast and ovarian cancer
- Less risk of osteoporosis in later life period
- Lesser pos-partum depression

2) For the baby

- Best natural food having ideal composition for infants which is easy for
digestion & absorption and provides proper growth & development
- Available 24 hours a day
- Reduces mortality rate
- Lesser chances of becoming overweight or obese
- Lesser risk of allergic disorders
- Lesser nutritional deficiency
- Protection against infections
- Better motor and cognitive development
- Better configuration of jaw
- Less dental caries
- Lesser risk of cancer