Sutika Paricharya

The postnatal period or puerperium (sutika kala) begins immediately after childbirth. This period generally lasts for six weeks. The pelvic organs revert to the pre-pregnancy state, and the female body restores anatomical and physiological normalcy.

Contributors

Section/Chapter/topic	Sharira / Postnatal care (sutika paricharya)
Authors	Anagha S., Deole Y.S.
Reviewed by	Basisht G.
Affiliations	Charak Samhita Research, Training and Development Centre, I.P.G.T.& R.A., Jamnagar
Correspondence email	carakasamhita@gmail.com
Publisher	Charak Samhita Research, Training and Development Centre, I.T.R.A., Jamnagar, India
Date of first publication:	June 30, 2021
DOI	10.47468/CSNE.2021.e01.s09.063

Importance of postnatal care (sutika paricharya)

Postnatal care ensures proper nutrition for the woman to regain strength after pregnancy. The woman becomes weak due to labor and nourishing the fetus. Her body tissues (dhatu) lose structural as well as functional integrity. Labor pain and expulsion of uterine contents cause physical and psychological instability. Proper diet and lifestyle regimen during the postnatal period replenishes the tissue elements (dhatu) in the body. It helps to come back to the pre-pregnant state gradually.[A.S.Sharira Sthana 3/39]

It also ensures the prevention of postnatal disorders and lactation for the nutrition of infants.

This article describes ancient practices of postnatal care. These practices are significantly changed in today’s era. However, these practices might provide insights into preparing a safe, cost-effective, and less toxic protocol for preserving health.

Duration of perperium

Ayurvedic rishis consider a lady as a puerperal woman (sutika) just after the expulsion of the placenta (apara) up to the onset of the next menstruation (artava). [Ka.Sa. Khila Sthana 11/6], [A. Hr. Sharira Sthana 1/101]

Specific diet and lifestyle is advised to restore equilibrium during this period of six weeks. [Su. Sa. Sharira Sthana 10/16],[A.S.Sharira Sthana 3/41]

Anatomical changes in the reproductive organs during pregnancy may revert within six weeks. However, the resumption of pre-pregnancy physiology at hormonal level controlling the ovarian and endometrial cycles in the menstrual physiology may take more time. So, this period can be extended further as four months [B.P. Purva Khanda 4/5-6] to 6 months [Ka. Sa. Khila Sthana 11/52-53] considering the individual variations.

Principles of postnatal management

Vata dosha and agni (digestive capacity) are the two key factors considered for postnatal management. Vata dosha is aggravated in the pelvic region by the creation of empty space after the expulsion of the fetus from the uterus.Management of vata dosha is done to prevent any possible complications and ensure smooth recovery from distorted anatomy and physiology in the female body. The digestion capacity (agni) is deranged due to physiological changes during pregnancy. Therefore, protection and stimulation of digestive capacity by diet and herbs having (deepana and pachana) effect is recommended. The nourishment therapy (brimhana) and rejuvenation therapy (Rasayana) can be useful only after proper management of vata dosha and agni.

General care during puerperium (samanya paricharya)

Immediate care after delivery

Immediate interventions in the labor room (sutikagara) include aseptic precautions, ensuring the proper evacuation of uterine contents, monitoring bleeding per vagina, vaginal packing is done. [Ka.Sa.Khila Sthana 11/18-22]

The woman is advised to rest in a hunch back position. Rubbing and massaging the back region, pressing the abdomen and flank, compression of the abdomen, and wrapping around with a clean and long cloth are recommended. [Ka. Sa. Khila Sthana 10]

The woman is then advised to sit over a small chair covered with a leather bag filled with hot oil processed with sida cordifolia (Bala taila) and sudation in the vaginal region with poultice prepared with drugs like Callicarpa macrophylla (priyangu). [Ka.Sa. Khila Sthana 10]

Vaginal packing just after the delivery is recommended in case of excessive bleeding. [Y.R. Streeroga Chikitsa]

Postnatal care

Postnatal care includes the following guidelines :

• Psychological support (ashwasana) [Ka.Sa.Khila Sthana 11/18]

• Internal administration with diet and medicines (abhyantara upakrama)

• External therapies (bahya upakrama)

Internal administration with diet and medicines (abhyantara upakrama):

Administration of fats :

Oral administration of fatty substance (sneha) with powder of panchakola (mixture of Piper longum (pippali and pippalimula), Piper chaba Hunte (chavya), Plumbago zeylanica (chitraka), and Zingiber officinale (nagara)) is prescribed. The quantity of fat is determined as per the digestive capacity. The scum of boiled rice (manda) is used as an after drink (anupana).

In contemporary practices, ghee is the most widely used form of fat in post natal care. Studies show that ghee prepared by traditional methods contain a higher amount of docosahexaenoic acid (DHA) and omega-3 long-chain polyunsaturated fatty acids. Maternal n-3 fatty acids levels, particularly DHA, are decreased during pregnancy. A low n-3 fatty acids level is found to be associated with postpartum depression (PPD). Oral administration of ghee may be useful to prevent the incidence of PPD.

Judicious administration of fats is recommended in the postpartum protocol. Ghee in greater quantity may lead to weight gain. Post-partum obesity is an associated risk factor for cardiovascular diseases. Therefore, the ghee administration is indicated in vata and pitta dominant constitution individuals. It shall be used with precautions in conditions associated with increased kapha dosha and meda dhatu.

Panchakola powder is observed to increase the serum levels of nutritional substances such as coenzyme Q10 & beta carotene and lengthen their serum half-lives. In addition, it can act as a thermal nutrient and increase the absorption of certain nutritional substances from the gastrointestinal tract by producing a local thermogenic action. Furthermore, these herbs have marked central stimulant activity, immune-stimulatory effect, and anti-inflammatory action. It also has bioavailability enhancer property and central dopaminergic activity. Thus, panchakola can help in relieving pain, promote uterine involution by contraction, autolysis and regeneration.

• If the patient is not suitable for administration of fats, then decoction of drugs alleviating vata, or laghu panchamoola (the roots of Solanum indicum, Solanum xanthocarpum, Desmodium gangeticum, Uraria picta, and Tribulus terrestris) is prescribed.

• Panchakola powder with hot water prepared by adding jaggery (gudodaka) for two to three days.

• Rice gruel with ghee(sneha yavagu) and processed with the drugs of the group called “vidarigandhadi gana” ( group of herbs) [Su.Sa.Sutra Sthana 38/4-5] for the next three days.

• Soup of Hordeum vulgare Linn.(yava), Ziziphus jujuba Lam(kola), Dolichos biflorus Linn.(kulatha) with an easily digestible diet is advised.

• After 12 days, meat soup of animals of arid region (jangala desha) is advised.

• Vegetables like pumpkin guard (kushmanda), radish, cucumber etc. fried in ghee are recommended.

• Boiled and cooled water should be used for drinking.

• Drugs that are vitalizing (jeevaniya), nourishing (brimhaniya), sweet, and alleviating vata are prescribed in general to restore the health of a woman. [A.S..Sharira Sthana 3/38]

External therapies:

• Whole-body massage (abhyanga), especially on the pelvic region with oil processed with Sida cordifolia (bala taila ).

• Application of a mixture of unctuous substances (ghee, oil, animal fat etc.) on the abdominal region and bandage using a long, comfortable, and clean cloth (udara veshtana).

• Per vaginal administration of oil and hot water sudation.

• Hot water bath or body wash with decoction prepared using vata alleviating drugs E.g. drugs of “Bhadradarvyadi gana” (group of herbs) twice a day.

• Sitz bath or hip bath (avagaha)

• Fumigation of the vaginal region with drugs like Saussurea lappa (Kushtha), Commiphora wightii (guggulu), Aquilaria agallocha (agaru) mixed with ghee.

• Oleation, sudation, and use of hot water are recommended to be followed at least for one month.

[Cha. Sa. Sharira Sthana 8/48], [Su.Sa.Sharira Sthana 10/16-17], [A.S.Sharira Sthana 3/38], [A.Hr.Sharira Sthana 1/99], [Ka. Sa. Khila Sthana 10], [Ha. Sa.Trutiya Sthana 53/1-5]

Day wise schedule in postnatal care

Day 1	Decoction of any of the herbs like Symplocos racemosa (lodhra), Terminalia arjuna(arjuna), Neolamarckia cadamba (kadamba), Cedrus deodara (devadaru), Pterocarpus marsupium Roxb (bijaka) and Ziziphus mauritiana (karkandhu), Fasting is recommended as per the strength of the patient.
Day 2	Combination of Zingiber officinale(nagara) and Terminalia chebula (haritaki) with jaggery (in the morning), warm soup of Dolichos biflorus Linn (Kulatha) (in the afternoon)
Day 3 & Day 4	Rice gruel mixed with “panchakola”, A combination of Cinnamomum zeylanicum, Cinnamomum tamala, Elettaria cardamomum, Mesua ferrea (collectively called chaturjata)
Day 5	Shali or Shashtika rice variety

This regimen can be repeated for 10-15 days. [Ha.Sa.Trutiya Sthana 53/1-5]. This diet is easy to digest, nourishing in the postpartum period.

The herbs stimulate digestion and help in restoring the equilibrium of dosha in the body. Research studies are needed to assess the efficacy of this protocol.

Special care during puerperium (vishesha paricharya)

Selection of fat according to the sex of baby

Ayurveda rishis advise the consumption of oil to the mother in case of delivery of a male baby. Ghee is advised in case of the delivery of a female baby. [Ka.Sa. Khila Sthana 11/32]

The reason might be dosha specific activity of oil and ghee. Ghee helps to pacify vata and pitta dosha. Oil helps to pacify vata and kapha dosha. These dosha variations might have been observed in the postpartum period as per the gender of the fetus.

Current research shows that the maternal immune milieu undergoes many changes based on the sex of the fetus. An increase in the levels of proinflammatory cytokines and proangiogenic growth factors is observed in the mother in the case of the male fetus. An increase in the expression of regulatory cytokines is found in the case of a female fetus. However, there was no fetal sex-based difference in their concentrations at the postpartum measurement. The reasons for physiological changes in the mother according to the gender of the baby are still unknown. Specific use of oil and ghee depending upon the gender of the baby is an area of research to be explored for better understanding.

Guidelines based on the place of living (desha)

Marshy place (anupa desha)

In marshy place, usually, diseases of vata and kapha dominance occur. Initially, fat should not be used in postpartum due to the dominance of moisture in the atmosphere of marshy area. A scum of boiled rice (manda) treated with appetizer drugs is given. Sudation, sleeping in a closed space (to avoid direct air exposure), use of hot substances is advised.[Ka.Sa.Khila Sthana 11/28-30]

Arid place (jangala desha)

In the arid area, diseases of vata and pitta dominance are usually prevalent. Since oleaginous substances are suitable (satmya) for people living in this area, they can be used in good quantity. [Ka.Sa. Khila Sthana 11/30, 31] So, the women are given ghee, oil, or other oily articles in large quantities and decoctions of drugs like Piper longum (pippali). If the woman is weak and not fit for intake of fat, she may be given the rice gruel. This regimen is followed for 3-5 days. Then the use of cereals mixed with unctuous substances in gradually increasing quantity is advised. [Su.Sa.Sharira Sthana10/17].

Ordinary place with average atmosphere (sadharana desha)

For those who reside in an ordinary place, general management with balanced use of oily and dry substances is recommended. [Ka.Sa. Khila Sthana 11/34]

In contemporary practices, variations in diet, regimens and medication given in the postnatal period are observed in different parts of India. These variations are observed as per the suitability of the women's geographical area, climate, habituation, and nutritional status.

General contra-indications during puerperal period

• Exercise, sexual intercourse, exposure to cold air, and excessive anger [B.P.Purva Khanda 4/2]

• Evacuative enema (asthapana basti) [Cha. Sa. Siddhi Sthana 2/14]

• Venesection(siravedha)[A.S.Sutra Sthana 36/8], [A.Hr.Sutra Sthana 27/7]

• Sternutatory drugs(nasya) [A.S.Sutra Sthana 29/11], [A.Hr.Sutra Sthana 20/12]

• Therapeutic purgation (virechana) [Su.Sa. Chikitsa Sthana 33/30]

• Excessive sudation (swedana)[A.S.Sutra Sthana 26/32]

These activities and therapies can adversely influence the natural process of rehabilitation during puerperium. Hence, they can be done safely after completion of puerperium.

Current Researches

• A clinical study conducted in 1000 puerperal women found that panchakola churna regimen 2 gm bd for first 10 days after 24 hours of normal delivery significantly reduces the incidence of secondary post partum hemorrhage (PPH). The group of panchakola churna regimen showed better outcome compared to the control group with conventional treatment, i.e. Inj. Pitocin 10 IU IM immediately after delivery of baby.

• A randomized placebo-control study conducted in 30 puerperal women was done for assessment of clinical efficacy of root of Piper longum (pippali moola) in reducing the postnatal abdominal bulkiness. Two capsules of the trial drug (1 capsule= 250mg) twice a day with buttermilk (takra) for 21 days were administered. Objective parameters like body fat percentage, body mass index, waist-hip ratio, abdominal skinfold thickness, supra-iliac skinfold thickness, triceps skinfold thickness etc. were applied. The therapy showed marked improvement in the study group than the placebo group.

List of theses done

1. Dr. Kolte C.G (1994): Study of Hingu in Sutikavastha, Department of Prasutitantra & Streeroga, Tilak Ayurved Mahavidyalaya, Pune.

2. Dr.PundeP.P (1995): Lohakhandayukta Panchmoola Kwathache Sutikavasthet upayoga, Department of Prasutitantra &Streeroga, Tilak Ayurved Mahavidyalaya, Pune.

3. Dr. Mamta BS (1998): Management of Sutika - An Ayurvedic view, Department of Prasutitantra &Streeroga , Faculty of Ayurveda, IMS,BHU, Varanasi.

4. Dr. Srivasthava Sarika (2001): Role of Shigru in management of Sutikarti(Puerperal discomfort), Department of Prasutitantra & Streeroga, Faculty of Ayurveda, IMS,BHU,Varanasi.

5. Dr. Sunita Suman (2004): Management of Sutika with Panchkola Churna, Department of Prasutitantra &Streeroga,Faculty of Ayurveda, IMS,BHU,Varanasi.

6. Dr. Chaudhary Sachin (2005) : Efficacy of Panchkola Ghrita in Sutika Paricharya, Department of Prasutitantra &Streeroga ,NKJAMC,Bidar.

7. Dr. Kabara Deepa ( 2008) : A clinical study to evaluate the effect, Department of Prasutitantra & Streeroga, SDMAC, Kuthpady.

8. Dr. Wahi Meenu (2011) : A clinical study of the efficacy of Panchjeerak guda in Sutika Paricharya, Department of Prasutitantra &Streeroga ,NKJAMC,Bidar.

9.Dr. Shikha Sharma(2014) : Comparative study of Sutika Dashmmola and Dashmoola Kwatha in wellbeing of Sutika, Department of Prasutitantra &Streeroga ,NIA, Jaipur.

Theses on Management of episiotomy wound:

1. Singh S(1994) : Healing of Mooladhara Chedana and Yoni KshatajanyaVrana caused during labour with Jatayadi Gritha, Department of Prasutitantra &Streeroga, B.H.U. Faculty of Ayurveda institute of medical science,Varanasi.

2. Pardeshi (ku) AD(1996) : Vitapacchedavarti Snehana Upachara, Department of Prasutitantra &Streeroga ,M.U.H.S, Tilak Ayurved Mahavidyalaya, Pune.

3. Pandey M(1999) : Management of obstetrical wound by aloe, Department of Prasutitantra &Streeroga, B.H.U. Faculty of Ayurveda institute of medical science,Varanasi.

4. Patil SB (2004): A clinical management of Prasoota Yoni Kshata with Karpoora Gritha Prayo, Department of Prasutitantra &Streeroga. SNKJMC,Bidar, RGUHS.

5. Thapa S (2005): Effect of Sharapunkha(Tephrosiapurpurea)on Episiotomy wound healing, Department of Prasutitantra &Streeroga B.H.U. Faculty of Ayurveda institute of medical science,Varanasi.

6. Ballal V (2006): Clinical evaluation of effect of Kumari Majja and Haridra on Episiotomy wound, Department of Prasutitantra & Streeroga, SDMCA, Udupi, RGUHS.

7. Priyadarshini R (2010): A comparative clinical study of Durvaditaila and Jatyaditaila application on episiotomy wound, Department of Prasutitantra &Streeroga, SDMCA, Udupi, RGUHS.

8. Patil PN(2011) : A clinical management of mooladhara Chhedana (Sadhyovrana) with Yashtimadhu Siddha Gritha w.s.r.to episiotomy wound, Department of Prasutitantra &Streeroga, Shri. J.G.C.H societ’s ayurvedic medical college, Ghataprabha, Belgaum .

9. Rajkrinti (2019): Ayurvedic management of episiotomy wound : a clinico-experimental study, Department of Prasutitantra &Streeroga Department of Prasutitantra &Streeroga,IPGT &RA, Jamnagar.

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References