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Introduction

A woman is blessed with this inevitable process of delivering child which is also accomplished with intense prolonged pain and discomfort. So, every women eagerly awaits intervention in some manner which cut-short the prolonged pain and discomfort. In such circumstances, a methodical incision so called Episiotomy for the comfort of mother and easy exit of fetal child is the option provided by Obstetrician. This not only facilitates easy and safe delivery of the fetus but also minimizes the chances of laceration and various degree of tears. Episiotomy is definitely a need for vaginal delivery like forceps delivery, twin delivery, vacuum delivery, primigravida delivery, big baby etc.[1] If episiotomy is not performed on time, prolong stay of the head at the perineum can have adverse effect on

the fetus as well as on the mother. Though it is a small cut, being present near to all the flushing outlets of the body, it is prone to infections and further complications like wound dehiscence and healing by secondary and tertiary intention causing excessive fibrosis.The procedure told in Grabhini Paricharya [2] can prevent and reduce the incidence of vaginal and perineal tear when a large fetal mass is passing through somewhat constricted and narrow introitus suddenly it can variably cause some injuries in its passage. The above said soothika paricharya help in healing of these damages. [3]  On the other side, any freshly made or injuries due to trauma or acute incision on the perineum are considered under the heading of vrana. So the episiotomy, an incision given on the perineum can also be taken as Sadyovrana and managed accordingly. The episiotomy wound comes under the chinna vrana of agantuja vrana. The chinna variety of Sadyovrana can also be sutured and managed for the approximation of cut edges and for better healing, which is practiced in episiotomy wounds. These Sadyovrana are devoid of the involvement of the three sharirika doshas for a period of seven days according to the texts, after which there will be involvement of doshas. [4]  According to Sukhasadhya laxanas of Vrana, it is said that wound involving twak and mamsa are easily healed. Episiotomy wound is fresh wound involving twak and mamsa only, so it is easily healed.

Sushruta the father of surgery explained different types of vrana in detail. This chapter deals with the derivation, definition, classification, Lakshana, Saadhyaasaadhyata, Nidaana, Chikitsa etc. The destruction / break / rupture / discontinuity of body tissue / part of body, is called Vrana.” [5]

Definition : “As the scar of a wound never disappears even after complete healing and its imprint persisting life long, it is called the Vrana by the wise.” “The scar of Vrana remains throughout the life, hence it is called Vrana” [6]

Classification : [7] Almost all the Acharyas have classified Vrana into two catagories i.e. Nija and Aagantuja depending  upon  the  causative  factors.

1.Nija or Shaareeraja vrana: Sushruta has specially mentioned these Nija Vranas to be due to Vaataja , Pittaja, Kaphaja,  Raktaja, and  Sannipaataja. These are further classified into 15 types on the basis of permutation & combination of Tridoshas along with  Rakta.

Charaka has described Nija Vrana as only of 3 types i.e.due to Vaata, Pitta and Kapha.

2. Aagantuja vrana: [8] It is caused by trauma from Purusha, Pashu, Pakshi, Vyaala, Prapatana, Peedana, Prahara, Teekshnaaushadha, Agni, Kshaara, Visha, Kapaala, Shringa.

Sushruta has mentioned six types chinna, bhinna, viddha, kshata, picchita, ghrishta. According to Ayurveda, there are four stages of wound healing (Avastha of vrana)

A) Dushta (infected)

B) Shudha (Sterile)

C)Ruhyamana(Healing)
D) Rudha rana (healed)

Ist Stage-(Dushta vrana):There are many signs and symptoms of Dushta vrana after vitiation of Doshas as mentioned above.

IInd Stage: (Shudha Vrana) :Suddha Vrana is describe as soft well demarketed pink colored, which discharch pain and burning sensation.

IIIrd Stages:- (Ruhyamanaya vrana):- Where as aRuhyamana vrana has kapotvrana (greyish), Dischargeless edges with formation   of chipitika (Granulation tissue). [9]

IVth Stages:- (Rudha Vrana):- Rudha Vrana which is the last stage of having approximated edges skin color absence burning sensation pain. [10]

Sushrut describes around 24 causes of nonhealing or mal-healing of Vrana. They can be summarized as Krumi (external infective focus)  dietary and  habitual imbalance (Mithya Aahar Vihar), Psychological factors and non-approximation of Vrana. The most important factors, which is responsible for nonhealing wound is lack of medicine.

Episiotomy:- In a strict sense, episiotomy is incision on the Pudenda. Perineotomy is incision of the perineum. In common parallence, however the term episiotomy often is synonymous with perineotomy. It is a deliberate purposeful incision taken on perineum for easy delivery of foetus by enlarging the introital opening. The incision may be made in the midline, creating a median or midline episiotomy or it may begin in the midline but be directed laterally and downward away from the rectum, termed as mediolateral episiotomy.

Purpose of episiotomy:-

1) For prevention of irregular perineal tear.

2) To effect easy delivery

3) To cut short the 2nd stage of labour.

4) To protect the foetal head from compression and intracranial hemorrhage due to tentorial tears.

Indication:-

1) Primigravidae

2) Rigid perineum

3) Breech presentation

4) Before application of obstetric forceps.

5) Premature delivery

6) Prolong second stage with foetal distress.

7) Maternal distress in second stage of labour.

Anaesthesia:-

A) Local skin and muscles infiltration with 2% xylocain. B) Pudendal nerve block.

Timing of episiotomy:-

1) At the stage of crowning of the foetal head.

2) Before and after introduction of the forcep blades.

Types:-

1) Medial or midline

 2) Mediolateral

3) Lateral  

4) 4) J-Shaped

Midline verses Mediolateral episiotomy:-

Discussion

Vrana Chikitsa:

Charaka has mentioned 36 Upakramas for the treatment of Vrana where as Sushruta has mentioned 60 Upakramas among them Kashaaya, Kalka, Varthi, Sarpi, Taila, Rasakriya, Avachoorna these 7 are both Shodhana as well as Ropana. [11] Charaka has explained Samaanya and Vishesha Chikitsa for Vrana.

1. Shodhana:

Formed by shudh+plut bhava which means shoucham. It is one of the important measures in case of Vrana Chikitsa. Among 60 Upakramas as mentioned earlier Kashaaya, Varti, Kalka, Sarpi, Taila, Rasakriya and Avachoornana are the different methods for Shodhana.In case of Vrana associated with Durgandha, Kledha and Picchila Shodhana should be done using

Kashaaya of various Dravyas.

Shodhana Taila: In case of Vrana which has Utsanna Maamsa, Alpasraava etc.Shodhana

should be done with sesamum oil mixed with musterd oil.

2.Ropanaa:“Dhathorbhava anatprathyayena nivyannam.ropayathi vranamithi ropanaha.” Ropana means jananam, pradurbhavam. Ropana Kriya should be adopted in Vranas which are having the features of Shuddha Vrana. Kashaaya, Varthi, Kalka, Sarpi, Taila, Rasakriya and Avachoornana are the different methods for Ropana.

Ropana Taila: In case of Vranas Ropana Taila is advised.

Agantuja vrana Chikitsa: [12]

1. Saamaanya Chikitsa:

Immediate general treatment is to pacify the Ooshma released at the site of injury by Sheetala Kriya’s(cooling measures )[ i.e.like that of Pitta Chikitsa] along with use of Madhu, Ghrita for Shodhana. Sadhyo Vrana which has severe pain should be washed in warm Yashti Ghrita or Bala Taila often in order to mitigate the heat of Vrana. Drugs which possesses ashaaya,Sheeta,Madhura,Snigdha properties should be made use for Lepa. Snehapaana, Parisheka, Swedana, Lepa, Upanaaha, Snehabasti prepared from Vaatahara drugs should be adiministered. Agatunja Vrana can be cured by Mantra,Agada and external application of drugs in the form of paste.

2. Vishesha Chikitsa:

Chinna, Bhinna, Viddha Vranas --- Snehapaana,Seka,Upanaaha with Veshavaara, Krushara,Swedana with cereals, Snigdha lepa,Sneha Basti with Vaataghna Oushadha, Snigdha Sneha is prescribed

Ghrishta Vrana -----In order to pacify Ushna, Sheetala Aalepa, Parisheka should be done.

These should be treated with Choornas (of Saala,Arjuna etc.) after relieving pain (by applying Madhuka ,cold etc.)

Picchita Vrana -- Sheetala Lepa,Pariskeka should be done.

Avakrita Vrana --Use of Kalka.

Vicchinna and Pravilambita Vrana --Seevana, Bandhana, Avapeedana should be done.

Viddha Vrana---Removal of Shalya.

Ropana: Ropana means a factor, which promotes or quickens the healing process. At

present the modern system of medicine could not find such karma which promotes the process of healing except anti-infective and debriding agents. But the great ancient surgeon, Sushruta gave his attention towards the Ropana. Sushruta mentioned the Ropana

process in the form of Kashaya, Varthi, Ghrita, Taila, Choorna, etc.

Surgical treatment:- Chedana , Bhedana, Lekhana, Aaharana, Eshana, Vyadhana ,Visraavana , Seevana are the eight type of surgical methods. The chedana that is given to assist in normal delivery undergoes seevana karma and then it is treated in the lines of Sadyovrana.

Conclusion

Episiotomy is a surgical cut of the perineum performed in the second stage of labour in orderto widen the vaginal opening and thus facilitate the birth of an infant. In Ayurveda it is considered as chinna vrana. For the management of chinna vrana suturing and bandaging is indicated in our classics. In practice Lepana, Parishek with shodhan and then Ropan drugs, Snehapana, Seka, Upanaaha with Veshavaara, Krushara, Swedana with cereals, Snigdha lepa, Sneha Basti with Vaataghna Oushadha are used for wound healing.