Episiotomy Wound Care through Herbal Preparations - A Case Report

Akshita; Soni Kapil

doi:http://dx.doi.org/10.21760/jaims.8.5.36

Episiotomy Wound Care through Herbal Preparations - A Case Report

Akshita.^1*, Kapil S.²

DOI: http://dx.doi.org/10.21760/jaims.8.5.36

^1* Akshita, Post Graduate Scholar, Department of Prasuti Tantra Evam Stree Roga, RGGPG Ayurvedic College & Hospital, Paprola, Himachal Pradesh, India.

² Soni Kapil, Associate Professor, Department of Prasuti Tantra Evam Stree Roga, RGGPG Ayurvedic College & Hospital, Paprola, Himachal Pradesh, India.

The word mother itself is symbolic to God. Mother suffers much distress after childbirth due to painful perineum. Pain following episiotomy appears to be universal. Proper healing of episiotomy wound after delivery is a major concern. In Ayurvedic classics Ghritkumari (Aloe vera) has been mentioned as Varna Ropaka and Vishvataghani due to its Sheeta properties. Various studies have demonstrated the power of Aloevera on moisturizing, wound healing, fibroblast activity, collagen proliferation, angiogenesis, anti-inflammatory, antibacterial, antifungal, antiviral & antioxidant effects. The application of Aloevera gel is best if extracted directly. The fresh gel from the plant has superior wound healing abilities. Allantoin, a substance in Aloevera, has considered a cell proliferant stimulant and a chemical debrider. Aloevera increases collagen content and degree of collagen cross – linkage within the wound. A 27 years female patient (Primigravida) was admitted in PTSR IPD with FTP with Labor pains. She delivered a healthy female baby with Normal Spontaneous Vaginal Delivery with Right Mediolateral Episiotomy. To analyze the effect of Aloevera pulp dressing on perineal healing after a normal delivery with a right mediolateral episiotomy wound. Episiotomy wound was cleaned with Triphala decoction then fresh Aloevera pulp was applied every 8 hourly on episiotomy wound for consecutive seven days. This study is being done for determining the impact of fresh Aloevera pulp on episiotomy healing in a primiparous woman. The result was assessed by using REEDA Scale.

Keywords: Aloe vera pulp, Episiotomy, REEDA Scale, Wound heal, Case Report

Corresponding Author	How to Cite this Article	To Browse
Akshita, Post Graduate Scholar, Department of Prasuti Tantra Evam Stree Roga, RGGPG Ayurvedic College & Hospital, Paprola, Himachal Pradesh, India. Email:	Akshita, Soni Kapil, Episiotomy Wound Care through Herbal Preparations - A Case Report. J Ayu Int Med Sci. 2023;8(5):215-221. Available From https://jaims.in/jaims/article/view/2472

Introduction

Episiotomy is a surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labour to expedite delivery of the fetus. It is the commonest surgical intervention to facilitate the soft tissue outlet for easy and safe delivery and also to prevent the injury to perineal muscle and fascia & to reduce the stress and strain on the fetal head.^[1] Among the Sutika Roga there is a reference of Yoni Kshata, Yoni Bheda, Yoni Vibhinata, Yoni Shopha, Yoni Shula, Yoni Bhramsha, Yoni Dosha which suggest of perineal trauma causing these conditions.^[2] So, for prevention of perineal injury, episiotomy, a planned surgical incision was introduced into the practice. In Ayurvedic Samhita, description of episiotomy wound has not been given directly but it can be considered as Shudha Agantuja Vrana or Sadyovrana. Thus, for the healing of this Shudha Vrana its management can be done by using Dravya possessing Ropana, Shodhana, Vedanasthapan Property.^[3] Episiotomy is recommended in selective cases rather than as a routine. A constant care during the second stage reduces the incidence of episiotomy and perineal trauma. Inelastic perineum causing arrest or delay in descent of the presenting part as in elderly primigravida. Anticipating perineal tear in the case of big baby, Face to pubis delivery, Breech delivery, Shoulder dystocia. In the case of operative delivery: Forceps delivery, Ventouse delivery. Bulging thinned perineum during contraction just prior to crowning is the ideal time for episiotomy. During the forceps delivery, it is made after the application of blades. There are four types of episiotomies; median, mediolateral left or right, lateral and J - shape.

Plan of procedure

Poorva Karma: Part preparation, painting and draping.

Pradhana Karma: Episiotomy during second stage of labour and suturing of episiotomy wound

Paschat Karma: Treatment of Shudha Vrana with Prakshalan and aloevera gel application.

Case Report

27 years female patient primigravida was admitted in PTSR, IPD with Full Term Pregnancy with Labour pains. She delivered a healthy female baby with Normal Spontaneous Vaginal Delivery with Right Mediolateral Episiotomy.

History of Past Illness: No significant Past History.

History of Surgery: No history of any surgical intervention.

Family History: Mother was suffering from DM II.

Clinical Examination

Pulse	80/min
BP	122/80mm of Hg
Temp.	98.4degree F
RR	18/min
Agni	Madhyama
Koshtha	Maadhyama
Prakriti	Kapha Pradhan Vata Anubandhi
Sara	Rasa-Raktasara
Mutra	Samyak
Mala	Samyak

Menstrual History

Duration - 2 to 3 days

Interval - 32 to 34 days.

Amount - 2 pads/day

Pain, Smell, Clots - Not present

Obstetric History: Primigravida

B/L Breast

Milk secretion - Adequate,

Breast Feeding - Established,

Engorgement and Tenderness not present.

Per Abdomen

Uterus Contracted.

7-8cm above pubis symphysis

Lochia

Amount - 2 pads per day

Smell - Not present,

Clots - not present

On Examination

All stitches intact,

Wound Healthy,

No abnormal Discharge present,

Mild Tenderness Positive

Investigations

WBC - 7.7X 1000/µl	B.Urea - 26mg/dl
RBC - 4.98X 100000/µl	S. Creat - 0.6 mg/dl
Hb - 12.6 gm/dl	TSB - 0.6mg/ dl
HCT - 39.9%	DSB - 0.2 mg/dl
MCV - 80.1/Lt	SGOT - 28 IU/l
MCH - 25.3 pg	SGPT - 36 IU/l
MCHC - 31.6 gm/dl	HIV - NR
PLT - 242X 1000 µl	VDRL - NR
L% - 31.0%	HBsAG - NR
M% - 12.4%
N% - 56.6%
ESR - 25mm/hr
FBS - 86 mg/dl

Plan of Treatment

Sthanik Chikitsa

Episiotomy wound was cleaned with Triphala decoction then fresh Aloevera pulp was applied every 12 hourly followed by Yoni Dhoopan with Kushthadi Dravyas (Kushta, Guggul, Agru, Ghee) on episiotomy wound for consecutive 7 days.

Shaman Chikitsa

SN	Drugs	Ingredients	Dose	Anupana
1.	Prataplankeshwar Rasa	Purified Mercury, Purified Mica, Purified Sulphur, Black Pepper, Iron Bhasam, Counch Shell Bhasam, Cow Dung Cake Bhasam, Aconitum Ferox	125 mg BD After meal	Honey
2.	Panchkol Churan	Pippli, Pipplimool, Chavya, Chitrak, Shunthi	3gm BD after meal	Gudodak
3.	Amlaki Rasayan	Amla, Madhu, Ghee, Pipli, Amla Ras, Khand	3gm BD after meal	Milk
4.	Dashmool Kwath	Agnimanth, Patla, Gambhari, Shyonak, Gokhru, Brihati, Kantkari, Shalparni etc.	100ml BD	-

Procedure for fresh aloevera pulp application on episiotomy wound

Step I: Wash Aloe vera stalk under running water.

Step II: Remove the skin of Aloe vera and scrap the fresh aloe vera pulp using sterile knife & place in a sterile bowl.

Step III: Wear gloves and clean the perineum with Triphla decoction and dry with Gauze Piece.

Step IV: Apply fresh Aloe vera pulp on the episiotomy wound and cover the whole edges.

Yoni Dhoopan^[4]
A chair having hole in the middle is used for this procedure.

Patient is allowed sit on the Dhoopan chair after voiding the urine.

The Dhoopan Dravyas are lit in Dhoopan Patra which is placed below the chair.

The smoke coming from the Dhoopan drugs reach upto the episiotomy wound for fumigation.

Dhoopan Patra

Pathya & Apathya:

Pathya^[5]: Sutika should consume Jeerna Shali, Odana which is made warm, unctuous and taken with Jangala Mamsa. Soup prepared from Tanduliyaka, Jeevanti, Vartaka, Patola, Karvellaka, Dadima, Amalaki etc.

Sutika should not sleep during day, should remain inside house devoid of breeze.

Apathya^[6]: Sutika should not consume Navadhanya, Masha, Tila, Kalaya, Kulatha, Nishpava, Harita, Shaka, Katu, Amla, Lavana Rasa, Sushka Shaka eatables made from Pishta Aja, Avika, Anoopa Mamsa, Sheeta Udaka, Krushara, Paayasa, Dadhi, Dugdha etc. Avoid using Maireya, Arishta, Aasava, Seedhu.

Sutika should avoid Vata, Aatapa, Raja, Dhoom, Atibhojana, this will inhibit the process of wound healing & therefore it should be avoided.

Assessment Criteria

Score	Redness
0	None
1	Mild - less than 0.5cm from each side of the wound edges
2	Moderate - 0.5cm to 1cm from each side of the wound edges
3	Severe - more than 1 cm from each side of the wound edges

Score	Oedema
0	None
1	Mild - less than 1cm from each side of the wound edges
2	Moderate - 1cm to 2cm from each side of the wound edges.
3	Severe - more than 2cm from each side of the wound edges

Score	Ecchymosis
0	None
1	Mild - less than 1cm from each side of the wound edges
2	Moderate - 1cm to 2 cm from each side of the wound edges
3	Severe - 1cm to 2 cm from each side of the wound edges

Score	Discharge
0	None
1	Serum
2	Serosanguinouus
3	Purulent

Score	Approximation
0	Closed
1	Skin separation 3mm or less
2	Skin and subcutaneous fat separation
3	Skin and subcutaneous fat and fascial layer separation

Results

Grades for overall effect of therapy for healing

SN	Before Treatment	After Treatment
Redness	2	0
Edema	2	0
Ecchymosis	1	0
Discharge	1	0
Approximation	1	0

Pain Intensity

Before Treatment	After Treatment
5 - Moderate	1 – Mild Pain

On 7^th postnatal day, the wound regeneration was assessed using REEDA SCALE.

The score was 0 which means episiotomy was healed properly.

Before Treatment

After Treatment

Discussion

The study is being done for determining the impact of fresh aloe vera pulp followed by Yoni Dhoopan on episiotomy healing in a primiparous woman. It revealed that the patient had a significant progress in wound regeneration by the application of fresh aloe vera pulp.

In Ayurvedic classics Ghritkumari (Aloe vera) has been mentioned as Vrana Ropaka and Vishvataghani due to its Sheeta properties. The result identified that Aloe vera has a property to penetrate and anaesthetize tissue.

By the action of moisturizing, wound healing - fibroblast activity, collagen proliferation, angiogenesis, anti-inflammatory, anti-bacterial, antifungal, antiviral and antioxidant properties. The fresh aloe vera pulp from the plant has superior wound healing abilities. Allantoin, a substance in Aloevera pulp, has considered a

cell proliferant stimulant and a chemical debrider. Aloevera pulp increases collagen content and degree of collagen cross-linkage within the wound.^[7,8]

Triphla: Kapha Shamaka, Stambhaka, Kashaya rasatmak, Vranaropana, antiseptic, astringent properties.^[9]

Yoni Dhoopan with Kushtadi Dravyas is Kaphahara, Sravahara and acts as anti-bacterial.

Shaman Chikitsa with Prataplankeshwar Rasa, Panchkol Churna, Dashmoolarishta enables Vatashamana, Rejuvenates the general health of puerperal women, improve lactation, involution and strength to the reproductive organs. It can also improve the process of healing.

The process of wound healing comprises of four stages

Haemostasis: During the first day of post-natal period the haemostasis is strongly achieved by the presence of lignon, saponin, prostaglandins and gamma - linolenic acid in aloe vera extract.

Inflammatory Phase: This phase is completed by the 3^rd day of postnatal period due to the presence of mannose phosphate, Vitamin A and C, aminoacids such as tryptophan and phenylalanine, salicyclic acid and fatty acids in aloe vera.

Proliferative Phase: The wound proliferation is successfully completed on 4^th post-natal day, due to the presence of glucosamine, anthraquinones and zinc in aloevera extract.

Maturation Phase: The maximum wound tensile strength is achieved by 5^th day of postnatal period with the action of Gibberellins - a plant growth hormone and high levels of protein in the aloe vera.

Conclusion

The procedure for application of fresh aloe vera pulp was done in aseptic conditions. The assessment and obstetrical history were collected by interview and observation method. The procedure was carried out twice a day for a period of 7 days during postnatal period. The wound healing was assessed by using REEDA Scale Scoring. The study resulted that application of fresh aloe vera pulp on episiotomy considerably increases the speed of episiotomy wound healing, which revealed that fresh aloe vera pulp application was one of the important and effectiveness intervention in improving episiotomy,

wound healing in early puerperal mothers. Patient achieved complete wound regeneration at the time of discharge.

Reference

1. Dutta DC. Text book of Obstetrics including perinatology and contraception, Konar H. 6th edi. New Central Book Agency: Calcutta; 2004.p

2. Tewari.P.V. Ayurvediya Prasuti Tantra Evam Stri Roga, part 1, Varanasi; Chaukambha Orientalia; 2011. P 559

3. Sushruta. Su 23/18, Chi 1/7 In: Y T Acharya (eds.) Sushruta Samhita Vartanasi: Chaukhambha Publications; 2006.p396

4. Maharishi Kashyap, Kashyap Samhita, Pt. Hemaraja Sharma, Vidyotini Hindi Commentary by Sri Satyapala Bhisagacharya, Khilsthana: Sutika Ukramaniyadhayay 11/22, 2018. Pg. 467

5. Sharma Priya Vrat. Sushruta Samhita Sutrasthan su.su 19/34 Varanasi; Chaukhamba orientelia; 2010.P – 2011

6. Sharma Priya Vrat. Sushruta Samhita Sutrasthan Su. Su 19/16-19 Varanasi; Chaukambha orientelia;2010. P -207

7. Hartawan, Eko Yulianto. 2012.SejutaKhasiatLidahBuaya. Jakarta: PustakaDiantara

8. Saptoningsih Adan, Jatnika , 2010 . MeraupLaba Dari LidahBuaya.Jakarta:Agro Media Pustaka.

9. Bhavprakash Nighantu of Sri Bhavmishra, Commentatory by Padmshri K.C. Chunekar, Chaukhamba Bharti Academy, Varanasi, 2015, HHaritkyadi Varga, 12.

Manuscript Received	Review Round 1	Review Round 2	Review Round 3	Accepted
2023-03-25	2023-03-27	2023-04-03	2023-04-10	2023-04-16
Conflict of Interest	Funding	Ethical Approval	Plagiarism X-checker	Note
Nil	Nil	Yes	18%

Case Report

Episiotomy Wound Care

Journal of Ayurveda and Integrated Medical Sciences

Episiotomy Wound Care through Herbal Preparations - A Case Report

Akshita.1*, Kapil S.2

Introduction

Case Report

Results

Discussion

Conclusion

Reference

Akshita.^1*, Kapil S.²