Streeroga Paper 2 Part B

प्रसूति िन्त्र
&
स्त्रीरोग
Paper II
PART B
CHAPTER I: Stanaroga
 Stanakeela / Stanakeelaka
 Introduction:
When a lactating mother swallows Vajra (foreign body such as grass, insects, grains,
stones, hairs, wood, etc.) along with food, and Vajra does not get digested and
metabolized, it will cause Stanakeelaka.
Stana = Breast
Keela = Nail
It is known Stanakeela as it is a breast disease which persists like a hard nail.
 Samprapti:
Vajra gets moistened and is propelled by Vayu along with Ahararasa. It reaches
Stanyavaha Sira and causes vitiation of Srotas in the mother. It settles in breast and
causes Stanakeelaka.
 Lakshana:
i) Samanya Lakshana = Ajeerna, Arti, Glanee, Ruja, Aruchi, Parvabheda,
Angamarda, Shiroruja, Kshavathu, Graha, Kaphotkleda,
Jvara, Trishna, Vidbheda, Mutrasangraha
ii) Vishista Lakshana = Stana Stambha & Srava, Shotha, Sirajalena Santata,
Shoola, Daha, Severe tenderness
 Bheda: - 3
1) Vataja (Quick relief)
2) Pittaja (Early onset & suppuration)
3) Kaphaja (Long lasting)
 Mode of expulsion:
If Vajra does not reach the head, extremities or abnormal passages, it comes out
quickly along with milk and blood by sucking of child or by compression.
 Chikitsa:
- Ghritapana (Srotani get softened and Vajra gets expelled easier)
- Extraction of milk, Massage
- Sheeta seka, Pralepa vireka, Pathya bhojana
- Drainage before suppuration
- Incision after suppuration
 Granthi
Granthi is a kind of swelling which is hard, knotty and rough.
 Bheda:
1) A. Sushruta = Vataja, Pittaja, Kaphaja, Medoja, Siraja
2) A. Charaka = Vataja, Pittaka, Kaphaja, Medoja, Siraja, Mamsaja
3) A. Vagbhata = Vataja, Pittaja, Kaphaja, Medoja, Siraja, Mamsaja,
Raktaja, Asthija, Vranaja
 Samprapti:
- Aggravated Doshas (VPK) vitiate Mamsa & Rakta to cause Granthi.
- Aggravated Vata Dosha with Kapha Dosha vitiate Meda to cause Medoja Granthi.
 Vataja Granthi:
- Shula, Krishna Varna, Amridu (similar to a filled urinary bladder)
- Discharge of fresh blood in case of rupture.
 Pittaja Granthi & Raktaja Granthi:

- Daha, Shula, Rakta / Peeta Varna, Paka (fast suppuration)
- Discharge of hot blood in case of rupture.
 Kaphaja Granthi:
- Sheeta, Kandu, Kathina, Sthula, Alpa-shula, Varna Tvachat (colour like skin)
- Discharge of thick pus in case of rupture.
 Medoja Granthi:
- Shlakshna, Kandu, Sthula, Alpa-shula
- Discharge similar like Taila / Ghrita in case of rupture.
 Siraja Granthi:
- Protuberant round, painful & mobile Siraja Granthi is Kricchrasadhya.
- Painless, fixed, large situated over Marma is Asadhya.
 Mamsaja Granthi:
Shlakshna, Kathina, Sthula, Sira (network of veins), Varna Tvachat
 Asthija Granthi:
Protuberant or depressed Granthi developing after fracture or trauma.
 Vranaja Granthi:
- Consumption of all Rasa by a person having unhealed ulcer or immediately
following its healing or not dressing a fresh ulcer or wound or due to vitiation by
Vayu or due to undischarged blood following a trauma.
- Granthi with Kandu and Daha.
 Chikitsa:
1) Ama-avastha -> Shopha Chikitsa
2) Pakva-avastha -> Vrana Chikitsa
 Pathya-Apathya
1) Pathya: Rakta Shali, Purana Ghrita, Yava, Mudga, Patola, Rakta Shigru, Guggulu
2) Apathya: Dugdha, Ikshu, Anupa Mamsa, Madhura, Guru, Abhishyandi Ahara
 Stanagranthi
There is no direct reference for Stanagranthi in the classical Ayurvedic textbooks.
Nidana, Lakshana & Samprapti of Granthi should be considered.
 Types of Breast Lumps:

1) Fibrocystic Breast Disease / Fibroadenosis
2) Fibroadenoma
3) Breast Cyst
4) Lipoma Breast
5) Mastitis
6) Breast Cancer
7) Pappiloma
8) Hamartoma
9) Fat Necrosis
1) Fibrocystic Breast Disease / Fibroadenosis

- Most common benign lesion of the breast.
- Occurrence: 25-45 years of age
- Cause: Fluctuation of hormones during normal menstrual cycle.
- Symptoms: Breast pain -> start prior to menstrual cycle; it may be dull,
severe, intermittent or continuous; Tenderness
- Features: Round & smooth borders of the breast; Rubbery, movable mass
2) Fibroadenoma
- Most common benign tumor of the breast.
- Synonym: Breast mice
- Occurrence: 20-35 years of age
- Cause: Result of excess growth of glands and connective tissue.
- Symptoms: Asymptomatic
- Features: Well rounded, smooth & solid; Rubbery, movable mass
3) Breast Cyst
- Fluid filled sac within the breast; normally resolves by itself after menopause.
- Occurrence: > 35 years of age
- Cause: Result of excess growth of glands and connective tissue.
- Symptoms: Breast pain or tenderness at the area of the breast lump
- Features: Smooth, easily movable, round or oval lump with distinct edges
4) Lipoma Breast
- A benign tumor of the breast composed of overgrowth of normal fat cells.
- Lipomas of the breast usually grow slowly and increase in size over a period of
long time.
- Painless, palpable, mobile, soft
5) Mastitis
Mastitis is the inflammation of breast tissue which may or may not be associated
with bacterial infection.
-> Refer to Mastitis later in the chapter for details.
6) Breast Carcinoma
Breast carcinoma is a malignant proliferation of epithelial cells lining the duct /
lobules of the breast.
-> Refer to Breast Carcinoma later in the chapter for details.
7) Pappiloma
A small solid benign tumor with a clear cut border that projects above the
surrounding tissue (e.g. wart).
-> Intraductal pappiloma:

Small benign wart-like growth in a milk duct of the breast; usually painless.
Types: a) Solitary
b) Multiple
8) Hamartoma
A benign tumor-like structure made up of an abnormal mixture of normal tissues
and cells from the area in which it grows.
9) Fat Necrosis
A lump of dead or damaged breast tissue that sometimes appears after breast
surgery, radiation or other forms of trauma.
 Samanya Chikitsa:
- Kvatha: Varuna-Shigru Kvatha, Punanarvadi Kvatha, Dahamula Kvatha
- Gutika: Kanchanara Guggulu, Kaishora Guggulu
- Churna: Triphala Churna, Guduchi Churna
- Rasa Yoga: Arogyavardhini Rasa, Nityananda Rasa
 Arbuda
अर्ब त िं साने ।
That which causes harm / kills is known as Arbuda.
Location, etiology, clinical features, involvement of Dosha and Dushya of Granthi and
Arbuda are identical. Arbuda is larger in size compared to Granthi.
 Samprapti: Dosha prakopa -> Mamsa dusti -> Arbuda lakshana
 Lakshana: वृत्तिं स्थिरिं मन्दरूजिं म ान्तमनल्पमू लिं तिरवृद्ध्यपाकम् ।

- Vritta (round)
- Sthira (stable / fixed)
- Mandaruja (mild pain)
- Mahantam-Analpamula (deep seated roots)
- Chiravriddhi (grows slowly)
- Apaka (never suppurates)
 Bheda: वािे न तपत्ते न कफेन िातप रक्तेन मािं सेन ि मे दसा ि ।

1) Vataja
2) Pittaja
3) Kaphaja
4) Raktaja
5) Mamsaja
6) Medoja
 Sadhya-Asadhyata:
Raktaja & Mamsaja Arbuda are Asadhya. Arbuda with discharge, strong roots and
located on Marma are also Asadhya. The remaining can be treated.
 Samanya Chikitsa:
- Arbuda is a condition in which Mamsa Dhatu is mainly vitiated. Chikitsa for Masaja
Roga is Shodhana, Kshara and Agnikarma.
- Chedana karma should be done for Granthi, Arbuda, etc.
- Patana (incision) should be done by avoiding Marma; followed by Lepana with
Saindhava and Ghrita.
- Lepana with Kshara made from Mulaka and Haridra mixed with Shankha Churna.
- Shopha & Vrana Chikitsa
- Vatashamaka Dravya and Madhura Gana Dravya are useful
 Stanarbuda
(Breast Carcinoma)
There is no direct reference for Stanarbuda in the classical Ayurvedic textbooks.
The following can be considered as Stanarbuda:
 Samprapti: Dosha prakopa -> Mamsa dusti -> Arbuda lakshana

Samprapti Ghataka:
Dosha -> Triodoshaja, Kapha pradhana
Dushya -> Rakta, Mamsa, Meda
Srotani -> Raktavaha, Mamsavaha, Medovaha, Stanavaha
Adhisthana -> Stana
 Raktarbuda:
Lakshana:
- Mamsa-ankura (muscular sprout)
- Ashu vriddha (fast growing)
- Pradusta Raktasrava(vitiated blood discharge)
- Chirapaka / Apaka (slow ripening with pus / No ripening with pus)
Upadrava: Raktakshaya, Pandu

Sadhya-Asadhyata: Asadhya
 Mamsarbuda:
Lakshana:
- Avedana (painless)
- Snigdha (unctuous)
- Vaivarnya (discolouration)
- Apaka (no suppuration / pus)
- Ashmopa (stony hard)
- Aprachalpa (immovable)
Nidana: Atimamsa bhojana, Mamsa dusti

Sadhya-Asadhyata: Asadhya
 Adhyarbuda: One Arbuda develops over a previous one.
 Dvirarbuda: Two Arbuda are growing simultaneously.

 Breast Carcinoma
Breast carcinoma is a malignant proliferation of epithelial cells lining the duct / lobules of
the breast.
It is the second most common cause of cancer death in woman (after lung cancer).
 Risk factors:
- Early menarche
- Late menopause
- Late first pregnancy or non-lactation
- Hormones (endogenous oestrogen)
- Oral contraceptives, Hormone replacement therapy
- Breast irradiation
- Family history
 Presentation:
- Non-tender lump (upper outer quadrant)
- Skin changes -> Dimpling, ulceration, Peau d’orange (skin of an orange)
- Nipple changes -> Inversion, ulceration, distortion
- Non-milky discharge; sometimes bloody
- Palpable axillary / cervical lymph nodes
 Types: - 2
1) In-Situ (non-spreading)
2) Invasive (spreading)
a) DCIS Ductal Carcinoma In-Situ

b) LCIS Lobular Carcinoma In-Situ
c) IDC Invasive Ductal Carcinoma (most common ~80%)
d) ILC Invasive Lobular Carcinoma (second most common)
e) Paget’s Disease of the Nipple
f) Inflammatory Breast cancer
g) Recurrent & Metastatic Breast Cancer
-> Paget’s Disease of the Nipple:

- A rare form of breast cancer
- Cancer cells collect in and around the nipple
 Diagnosis:
Biopsy, Blood cell counts, Blood marker test, Bone scan, Breast MRI, CT scan,
PET scan, Chest X-ray, Ductal lavage, Mammograms
 Treatment:
Surgery, Chemotherapy, Radiation therapy, Hormonal therapy, Biological therapy
 Pathya-Ahara in Stanaroga
Ama-avastha: Jeerna Shyamaka, Kulattha, Lashuna, Rakta Shigru, Karavela, Punarnava,
Chitraka, Kshaudra
Pakva-avastha: Purana Rakta Shali, Ghrita, Taila, Mudga Rasa, Vilepi, Shaka, Kadali,
Patola, Taptasheeta Ambu, Dhanvaja Rasa
 Stanavridradhi
(Breast Abscess)
There is no direct reference for Stanavidradhi in the classical Ayurvedic textbooks.
The following can be considered as a description of Stanavidradhi.
 Samprapti: The Doshas which are vitiated due to the causative factors similar as for
Bahya Vidradhi, reach the Stanavaha srotas leading to Stanavidradhi lakshana.
 Nidana:
- Paryushita (stale), Ati-ushna ruksha shuska vidahi Ahara
- Sleeping on an uneven bed
- Abnormal actions
- Rakta prakopaka nidana (Atapa, Agni, Kshara, etc.)
 Bheda:
1) Vataja
2) Pittaja
3) Kaphaja
4) Sannipatika
5) Raktaja
6) Abhigataja
 Lakshana:
1) Vataja
- Atyartha Vedana, Parusha, Bhrama, Anaha, Spandana
- Shyava Aruna Varna
- Vishamasamsthiti (uneven swelling; increases & decreases)
- Chitra Utthana Paka (develops and suppurates in a variable manner)
- Tanu srava (thin discharge)
2) Pittaja
- Jvara, Daha, Trishna, Moha
- Rakta Tamra Krishna Varna
- Kshipra Utthana Paka (develops and suppurates quickly)
- Peeta srava (yellow discharge)
3) Kaphaja
- Sheeta, Stabdha, Alpavedana, Kandu, Hrillasa, Jrimbha, Aruchi, Gurutva
- Peeta Shveta Varna
- Chira Utthana Paka (develops and suppurates slowly)
- Pandu srava (pale discharge)
4) Sannipatika
Vataja Pittaja Kaphaja Lakshana
5) Raktaja
- Krishna Sphota
- Shyava Varna
- Tivra Daha, Ruja, Jvara
- Pittaja Lakshana
6) Abhigataja
Due to injury (weapons, falling, etc.) and uncongenial diet, heat generation
occurs which spreads due to Vayu. Pitta gets aggravated and withholds Rakta.
- Pittaja & Raktaja Lakshana
 Chikitsa: Vrana & Shopha Chikitsa, Patana, Jalaukavacharana
 Breast Abscess
Breast abscess is an acute inflammation / infection with collection of pus within the
breast tissue.
It may be a complication of infective mastitis.
 Clinical features:
- Fluctuant swelling develops in a previously inflamed area.
- Pus discharge may be present.
 Types:
i) Lactational Breast Abscess
ii) Non-lactational Breast Abscess
i) Lactational Breast Abscess

- Breast abscess in lactating women.
- Develops within first 6 weeks of breastfeeding.
- Causative organism: Staphylococcus aureus, Streptococci
- Cause: Drainage of milk is affected which leads to stagnation of milk and
further to infection.
- Symptoms: Pain, Swelling, Tenderness, Cracked nipple
ii) Non-lactational Breast Abscess

- Breast abscess in non-lactating women.
- Develops commonly around the age of 32.
- Sub-types: a) Central infection
b) Peripheral infection
 Investigations:
- Breast ultrasound
- Diagnostic Needle Aspiration
- Nanogram
 Stanashopha
(Mastitis)
There is no direct reference for Stanashopha in the classical Ayurvedic textbooks.
The following can be considered as a description of Stanashopha.
 Bheda:
1) Nija -> Vataja, Pittaja, Kaphaja, Dvandvaja, Sannipatika
2) Agantuja
 Nidana:
1) Nija Shotha Hetu:
- Krisha or Abala due to excessive Shodhana, Upavasa or Vyadhi
- Kshara, Amla, Tikshna, Ushna, Guru Ahara
- Dadhi, Mritika, Shaka
- Apakva Ahara, Viruddha Ahara, Dusta Anna
- Achesta (sedentary life style)
- Na Deha Shuddhi (non-performing of Shodhana karma even if indicated)
- Marma-upaghata (injury to vital points)
- Vishama prasuti – Garbhapata, Garbhastrava, Mritagarbha, Dusta prasava
- Mithya-upachara
- Pratikarma (complication of shodhana)
2) Agantuja Shotha Hetu:

Abhighata (trauma) due to:
- Kastha (Wood)
- Ashma (Stone)
- Shastra (Weapon)
- Agni (Fire)
- Visha (Poison)
 Samprapti:
Shopha / Shotha / Shvayathu is generally caused by vitiation of all 3 Doshas.
- If Vatamarga is obstructed in the lower part of the body by Kapha, Rakta and Pitta,
Vata moves upwards and lodges at Ura pradesha leading to NIja Stanashopha.
- Agantuja Stanashopha is caused by direct trauma to the breast.
 Purvarupa: Ushma, Daha, Siranama Ayama (dilation of vessels)
 Samanya Lakshana:Gaurava, Utsedha, Ushma, Sira tanutvam, Lomaharsha, Vaivarnya

 Vishesha Lakshana:
1) Vataja
- Chala, Tanu tvak, Parusha, Supti
- Aruna Asita Varna
- Divabali (increases during the day)
- Non-pitting oedema
2) Pittaja
- Mridu, Sagandha, Bhrama, Jvara, Sveda, Trishna, Mada, Sparsha Ruk
- Asita Peeta Raga Varna
- Akshi Rakakrita (reddish eyes)
- Excessive and swift burning sensation and suppuration.
3) Kaphaja
- Guru, Sthira, Praseka, Nidra, Vami, Arochaka, Agnimandya
- Pandu Varna
- Ratribali (increases during the night)
- Pitting oedema
 Upadrava: Chardi, Shvasa, Aruchi, Trishna, Jvara, Atisara, Daurbalya
 Apathya: Gramya, Udaka, Anupa Mamsa; Shuska Mamsa & Shaka; Navanna,
Pistanna, Guda, Dadhi, Tila, Madya, Samashana, Guru Ahara, Divasvapna, Maithuna
 Chikitsa:
1) Nija Shopha Chiktsa:
- Ama-avastha -> Langhana Pachana Chikitsa
- Vamanadi Chikitsa if Dosha are excessively aggravated

- Vamana Chikitsa specifically because Dosha are located in upper part.
- Snehana Chikitsa if Shopha is caused due to Ruksha; vice-versa
- Niruha Basti if Vataja Shopha is associated with Vibandha
- Vata-Pittaja Shopha -> Tiktaka Ghrita
- Shopha associated with Murcha, Arti, Daha, Trishna -> Ksheera pana
- Kaphaja Shopha -> Gomutra pana, Takra, Kshara, Katu, Ushna Dravya
- Sannipatika Shopa -> रीिकीनागरदे वदारु सुखाम्बुयुक्तिं सपुननब विं वा ।
सवं तपर्ेस्रिष्वतप मू त्रयुक्तिं स्नािश्च जीर्णे पयसाऽन्नमद्याि् ॥
2) Agantuja Shopha Chikitsa:

Arista Bandhana, Vrana Bandhana, Mantra, Agada Pralepa, Svedana, Nirvapana
 Mastitis
Mastitis is the inflammation of breast tissue which may or may not be associated with
bacterial infection.
 Occurrence:
- 2-5% in lactating women
- < 1% in non-lactating women
 Types:
A) i) Infective Mastitis
ii) Non-infective Mastitis
B) i) Lactational Mastitis
ii) Non-lactational Mastitis
A) i) Infective Mastitis
- Causative organism: Mainly = Staphylococcus aureus

Other = Streptococcus, E. Coli
- Cause: ▪ Damage to the epithelium which allows bacteria to affect the breast
tissue.
▪ Improper attachment of the baby to the breast during breastfeeding
may cause trauma to the breast tissue, leading to an infection.
- Sub-types: a) Infection involves breast parenchymal tissue. Lactiferous ducts are

unaffected.
b) Infection gains access through lactiferous ducts.
- Incubation period: 1-2 weeks
- Signs & Symptoms: Malaise, Headache, Fever (>102°F / >39°C), Severe pain,
Wedge-shaped swelling of the breast, Tenderness
- Complication: Breast abscess
- Management: a) Prophylactic = Thorough hand washing before each feeding.

Cleaning of the nipple before & after feeding.
b) Curative = Antibiotics, Analgesics, Drainage in case of abscess

A) ii) Non-infective Mastitis
- Cause: Milk stasis due to poor breastfeeding technique.
- Management: ▪ Continue breastfeeding from the affected side, otherwise

stasis will increase and mastitis becomes worse.
▪ Improve breastfeeding technique.
▪ Antibiotics if no improvement is observed.
B) i) Lactational Mastitis
It is mastitis which occurs in lactating women.
B) ii) Non-lactational Mastitis

It is mastitis which occurs in non-lactating women, commonly around the age of 30.
- Signs & Symptoms: ▪ Peri-areolar pain, Tenderness, Nipple discharge

▪ Often accompanied with swelling.
 Galactocele
Galactoceles, also known as lactoceles, are the most common benign breast lesions,
typically occurring in young lactating women. However, they mostly happen on cessation
of lactation.
 Cause:
Occlusion of lactiferous ducts leading to formation of a cyst - galactocele - which
contains milk.
 Signs & Symptoms:

- Usually painless breast lump which develops over weeks or months.
- Lesions may be present as a single or multiple nodules & may be unilateral or
bilateral.
 Complications: Secondary infection with development of breast abscess.
 Investigations: Mammography, Ultrasound
 Management: Galactoceles are benign lesions which in most cases

spontaneously resolve by themselves.
CHAPTER II: Sthanika chikitsa
 स्नेहन & स्वे दन

स्ने न & स्वे दन are used as Purvakarma for Shodhana karma. Similarly, it is used as
Purvarkarma for Sthanika Chikitsa, especially for Uttarabasti. It is done to improve
absorption and circulation of Aushadha Dravya which is administered.
 स्नेहन is done in the form of Abhyanga, specifically on the legs, lower abdomen and
the lower back. It should be done for approximately 5 minutes on one area.
It softens the local tissue, promotes circulation and pacifies or regulates Vata Dosha.
Abhyantara Snehana with Chatursneha, Badara Rasa and Triphala Kvatha is

specifically done for Yoni- and Shukra Dosha.
 स्वेदन is done in the form of Nadisvedana. It should be directed at the same area
where Abhyanga was done
It is useful in case of coldness, pain, stiffness, heaviness; it induces softness, opens all
the minute channels and liquefies the Doshas.
Nadisvedana is tube fomentation in which the steam is generated by boiling the

specific liquids in a pot. The pot is attached with a pipe; through the pipe the steam is
directed towards the desired body part that required fomentation.
Nadisvedana Dravya:
i) Vataja Vikara: Ksheera, Eranda beeja, Tila beeja, etc.
ii) Kaphaja Vikara: Varuna, Guduchi, Eranda, Shigru, Mulaka, Sarshapa, Vasa, etc.
iii) Vata-Kaphaja Vikara: Panchamula, Sura, Mastu, Gomutra, Amla Dravya, etc.
 उत्तरबस्ति
उत्तरर्स्ि is the therapeutic procedure of administering medicinal drugs through intra-

uterine route.
 अधिष्ठान = िृ िीयाविब , तििीयाविब

 प्रयोग = वन्ध्यत्व, कष्टािब व, नष्टािब व, आिब वक्षय, पुत्रति / जाििी योतनव्यापि्
PCOD (Poly-Cystic Ovarian Disease), POF (Premature Ovarian Failure)
 अयोग = प्रसावकाल, गर्ब काल

Any inflammatory condition or infection in genital area or urinary tract.
 द्रव्य = िै ल, घृि
 औषि = योग आमातयक प्रयोग
फलघृि पुत्रति / जाििी योतनव्यापि् , POF
शिपुस्प िै ल वन्ध्यत्व (Anovulation), PCOD, POF
दशमू ल िै ल कष्टािब व, नष्टािब व
अपामागबक्षार िै ल वन्ध्यत्व (Tubal blockage)
गुडूच्यातद िै ल कष्टािब व, आिब वक्षय
 मात्रा = 5 ml; 1-2 ml only will be directly administered into uterine cavity.
 पररमाण = After cessation of menses: a) 3 days subsequently
b) 6 days subsequently
c) 3 days – 3 days break – 3 days
- Repetition: 3 cycles / 6 cycles / 9 cycles with break of 1 cycle after
each 3 cycles of treatment.
 काल = Morning
 क्रम = पूवबकमब , प्रधानकमब , पश्चात्कमब
1) पूवबकमब ▪ Required investigations to check the general health of the patient
and to rule out any inflammation or infection.
(TCDC, Hb, HIV, VDRL, HBsAg, Urinalysis)
▪ Patient should have empty stomach.
▪ अभ्यङ्ग (mainly on legs, lower abdomen & back)
▪ नाडीस्वे दन
▪ योतनप्रक्षालन (पञ्चवल्कल क्वाि)
▪ Separate procedure room, clean table
▪ Required instruments: Sponge-holding forceps, Sims’ speculum,
Anterior vaginal wall retractor, Vulsellum (Alli’s forceps), Basti Netra &
Basti Putaka (cannula & syringe), Cotton swap, Draping cloth
▪ िै ल / घृि should be warmed.
2) प्रधानकमब ▪ Early morning

▪ Patient should be in lithotomy position.
▪ Antiseptic measures (betadine)
▪ Draping of peripheral area
▪ Clean internal vagina with cotton swab.
▪ PS-examination
▪ Catch anterior lip of the cervix with vulsellum.
▪ Uterine sounding to know the position of uterus.
▪ Injection of Aushadha Dravya (1-2 ml) in warm state into uterine
cavity with the help of Basti Netra.
▪ Remove Basti Netra carefull from external os and remaining
Aushadha Dravya (3-4 ml) is injected into vagina.
▪ Pratyavartana (backward flow of Aushadha Dravya) should be
observed.
▪ Puta-Pottali
▪ Remove speculum
3) पश्चािकमब ▪ Head low position for 30 min - 1 h.

▪ Massage on lower abdomen for 10 min.
▪ Hot water bath fomentation for 30 min -1h.
▪ Removal of Pottali before micturition or latest after 2 hours to
prevent infection.
▪ Mild abdominal pain & slight vaginal bleeding may be normal.
▪ Precautions for the patient: Avoid spicy food, avoid heavy food, avoid
food which may cause constipation, avoid coitus, clean vaginal area
properly after micturition.
 उपद्रव = Uterine distension & severe pain if too much Basti Dravya is
administered directly into uterine cavity or if it is forcefully injected.
- Infection due to improper hygiene, white discharge, itching vulva,
burning sensation while urination.
- Lower abdominal pain for prolonged time.
- Oil embolism leading to Peritonitis -> Tenderness, pain, distension,
nausea, vomiting, diarrhea, constipation, minimal urine output,
anorexia, excessive thirst, fatigue, fever.
 धिधकत्सा = िन्द्रप्रर्ावटी / तत्रफला गुग्गुलु / गोक्षू रातद गुग्गुलु for 3 days, b.i.d.
शण्खवटी for 3 days, 1-2/d in case of pain.
एरण्डभ्रष्ट रीिकी 3-5gm at night with warm water in case of
constipation.
 Mechanism of Action:
- िै ल / घृि is used along with medicinal drugs to act as a carrier because the
endometrium, mucosa, etc. can absorb fat easier. Also, estrogen & progesterone are
lipid hormones, so Sneha Dravya have a stronger effect on them.
- After absorption of Aushadha Dravya, it reaches the blood and is circulated & acts on
the genital organs.
- पूवबकमब is done to improve absorption & circulation of Aushadha Dravya.

- फलघृि acts primarily on the uterus.
- शिपुस्प िै ल acts primarily on the ovaries.
- अपामागबक्षार िै ल does Lekahana Karma.
- उत्तरर्स्ि is useful in all types of infertility; it is usually performed along with other
treatments such as तवरे िन, योग र्स्ि & नास्य.
 योधनधपिु (Vaginal Poultice / Tampon)
योतनतपिु is a sterile cotton swap dipped in warm oil & placed in the vagina for therapeutic
purpose.
 अधिष्ठान = प्रिमाविब
 प्रयोग = आिब वदु तष्ट, योतनस्राव, योतनक्लेद, योतनपैस्िल्य, योतनकण्डू, योन्यशब
 द्रव्य = िै ल, घृि, क्वाि, क्षार
 औषि = जात्यातद िै ल, गुडूच्यातद िै ल, र्ला िैल, शिपुष्प िै ल, कुमारीमज्ज
 मात्रा = 5 ml
 पररमाण = 2 hours; 8-10 days
 काल = Morning / Evening; once per day
1) पूवबकमब ▪ Required investigations

▪ Clean table, sterile cotton swap
▪ Patient should empty the urinary bladder
▪ Medicinal liquid should be warmed
2) प्रधानकमब ▪ Aseptic measures

▪ Sterile cotton swap is dipped in warm medicinal liquid & placed in the
vagina.
▪ It should be kept for 2 hours maximum to avoid infection, and is then
removed & discarded by the patient independently.
3) पश्चािकमब ▪ Precautions for the patient: Avoid spicy food, avoid heavy food, avoid
 उपद्रव = Infection, Ulceration, Pain, Burning sensation
- The medication remains for a long time in the vagina, thus facilitating better
absorption of the drugs.
- It moistens and softens dry vagina.
- The medications restore the pH of vaginal flora which reduces chance of infenction.
- Vata Dosha gets subsided by use of warm medicated liquid.
- In 9th month of pregnancy, this procedure facilitates effacement and dilatation of
lower uterine segment.
 Vaginal Poultice / Vaginal Tampon
Packing the vagina with a tampon (gauze, strip, cotton wool or similar absorbent
material) is called tamponade.
 Indications:
- To contain the normal menstrual discharge.
- To stop oozing at the end of vaginal or cervical operation.
- To arrest secondary post-operative haemorrhage from the vaginal walls and cervix.
It should not be used for primary post-operative haemorrhage.
- To convey medication to the vagina and cervix.
- To control utero-vaginal prolapse complicated by decubital ulceration. The tampon
acts by establishing a normal circulation to promote healing. The application of
oestrogen cream to the packing in decubital ulceration prior vaginal hysterectomy
may also be helpful.
 Method:
- Tampons may be encased in a rigid container which allows their easy insertion; an
attached string permits their removal. Unless these are used, the vagina is generally
best packed with one continuous strip of gauze, the end being left protruding out.
If more than one tampon of cotton wool is inserted, a careful count must be made
and recorded to ensure that all are removed.
- Ordinarily, vaginal tampons are not left in place for more than 24 hours as they
become infected and offensive except in cases of haemorrhage where it is wise to
leave them for 48-72 hours.
 Complications:
- Infection
- Toxic shock syndrome
- Ulceration or excoriation
- Pain or burning sensation
 योधनवधति (Vaginal Suppository)
योतनवतिब is the therapeutic procedure of inserting a modified form of Vati Kalpana in Yoni
pradesha. The thickness should be like that of the thumb or index finger. It is left for a
short period or as needed or in case of dissolving type, it can be left in situ.
 अधिष्ठान = प्रिमाविब (योतन)

 द्रव्य = शोधक द्रव्य; अशोक, लोध्र, जीरक, कातिक, क्षार, सैन्धव लवर्ण, etc.
 औषि
▪ यविू र्णब + सैन्धवलवर्ण -> र्वन अकबक्षीरे र्ण -> वतिब -> कफज योतनव्यापद्
▪ वरा तपत्त -> वतिब -> श्लेष्मज योतनव्यापद्
▪ तपप्पली माष मररि शिावरी कुष्ठ सैन्धवलवर्ण -> वतिब -> श्लैस्ष्मकी योतनव्यापद्
▪ कुष्ठ तपप्पली अकब सैन्धवलवर्ण गोमू त्र -> वतिब -> कतर्णबनी योतनव्यापद्
 Method:
Vaginal suppositories are solid medications that are inserted into the vagina with a
special applicator. The body absorbs drugs from vaginal suppositories quickly. They
work faster than medications taken by mouth. This is because suppositories melt
inside the body and the medicine is absorbed directly into the bloodstream.
Requirements: Suppository, Applicator, Soap, Water, Towel, Sanitary napkins
Preparation:
- Wash the vaginal area and hands with mild soap and warm water, and dry well with
a clean towel.
- Remove any wrapping from the suppository.
- Place the suppository onto the end of the applicator. A pre-filled applicator already
contains medication.
- Hold the applicator by the end that does not contain the suppository.
Inserting the suppository:

- The patient should lie on the back with knees bent.
- Gently insert the applicator into the vagina as far as it will comfortably go.
- Press the applicator’s plunger as far as it goes. This will push the suppository far
back into the vagina.
- Remove the applicator from the vagina.
 योधनलेपन (Vaginal Ointment / Gel / Cream / Foam / Jelly)
योतनले पन is the therapeutic procedure of applying medicated paste inside the vagina.
Fresh drugs may be used or dry drugs are moistened to form a paste.
The paste is retained inside the vagina so that the medicine can be absorbed into the
blood stream. Application of paste on a wound promotes healing.
 पयािय = योतन पूरर्ण, योतन धारर्ण, कल्क धारर्ण

 प्रयोग = व्रर्ण, व्रर्ण शूल, व्रर्ण शोधन, शोफ
 द्रव्य = कल्क
 औषि
▪ पलाशर्ीज अपक्व उदु म्बरफल तिलिै ल मधु -> कल्क
▪ रसोन गृ धू म तवशाला तवडङ्ग कण्टकारी -> कल्क -> योतन शूल, योतन कृतम
▪ र्ाकुिी दे वदारु तनम्ब दारु ररद्रा असनमू ल िक्र -> कल्क -> योतनरोग
An ointment is a smooth oily substance. A gel is a thick, clear, slightly sticky substance.
A cream is a semisolid emulsion containing suspended or dissolved medication. A foam is
a dispersion of a gas in a medicated liquid resulting in a light, frothy mass. A jelly is a
colloidal semisolid mass of a water soluble medicated material, usually translucent.
Anti-fungal vaginal creams, commonly used for yeast infections:

- Clotrimazole
- Niconazole
- Tioconazole
Spermicides:
Spermicide is an agent that kills spermatozoa (sperm). Spermicide causes the sperm cell
membrane to rupture, so the sperm is unable to fertilize the egg. Creams, jellies, foams
etc., containing chemical spermicides are used as contraceptives.
- VCF (Vaginal Contraceptive Film)
- Encare
- Shur-Seal Gel
 योधनिूपन (Vaginal Fumigation)
योतनधू पन is the therapeutic procedure of fumigating the vagina with Dhupana Yantra; it is
often performed after योतनधावन.

 द्रव्य = गुग्गुलु, धत्तू र पत्र, शिपुष्प, etc.
 औषि
▪ र्ृ िीफल ररद्रा दारु ररद्रा -> कल्क -> धू पन -> योतनकण्डू
▪ मदनफल -> धू पन -> गर्ब सङ्ग, अपरासङ्ग
1) स्रोतोशोिन
Dhupana is Ushna, Tikshna and Sukshma; it induces Svedana which opens
minute channels and cleanses the Yoni.
2) कफघ्न & क्लेदघ्न

Dhupana is Ushna, Ruksha, Tikshna, Sukshma; hence it reduces Kapha & Kleda.
3) रक्षोघ्न
Dhupana is bactericidal and antiseptic due to Ushna, Ruksha, etc. or due to
Prabhava of specific Dravya.
 योधनिावन (Vaginal Douching)
योतनधावन is the therapeutic procedure of cleansing the vagina with medicinal decoction.
 पयािय = योतनप्रक्षालन, योतनरे िन, योतनसेक, योतनपररषेक

 द्रव्य = क्वाि
 औषि = पञ्चवल्कलक्वाथ, त्रिफलाक्वाथ, etc.
 मात्रा = 1 litre
 पररमाण = 5-10 min; 8-10 days after menstruation
 काल = Morning / Evening; once per day

▪ Separate procedure room, clean table, enema pot, sterile rubber
catheter or nozzle
▪ Clean cloth for patient
▪ क्वाि should be warmed

▪ Enema pot with warm decoction is kept at 5 feet height.
▪ Sterile rubber catheter or nozzle is inserted into vagina.
▪ प्रिमाविब is washed for 5-10 minutes by moving catheter / nozzle first
clockwise and then anti-clockwise direction.
3) पश्चािकमब ▪ Cleaning of external genital organ.

▪ Patient should remain in supine position for 15-20 minutes.
 उपद्रव = Infection & spread of infection, Irritation, PID
Warm irrigation of vagina cleans the local area, relieves pain and stimulates blood
circulation which supports the healing process of indicated diseases.
 Vaginal Douching
Vaginal douching is the irrigation or rinsing of the vagina. Vaginal douching is washing
the vagina with water or a mixture of fluids to eliminate odors and clean the vagina.
Most often, vinegar is mixed with the water, but some prepackaged douche products
contain baking soda or iodine. A few also contain antiseptics and fragrances.
One in five women between the ages of 15 and 44 use douches regularly.
 Types:
1) Cleansing (Not advised as a routine; it upsets vaginal flora and pH)
2) Antiseptic (Acriflavine, Povidine iodine solutions)
3) Therapeutic (Medicinal decoctions, Antibacterial solutions)
 Indications:
- Chronic vaginitis
- Chronic cervicitis
- Carcinoma cervix
- Sloughing following cervical cauterization
- Sloughing uterine polyps
 Method:
The safest method is to run the fluid from a douche can or bag suspended not higher
than 60 cm above the vagina. The tube from this leads into a blunt ended metal or
plastic nozzle which is inserted into the upper vagina. The fluid is allowed to flow
slowly by gravity for 5-10 minutes while the nozzle should be rotated in the vagina.
Care should be taken not to hit the cervix.
 Common reasons women report they use a douche include:

- Eliminating unpleasant odors
- Preventing pregnancy
- Washing away menstrual blood after a period or semen after sex
- Avoiding a sexually transmitted infection
However, douching does not accomplish any of these things.
 Complications:
- Women who douche regularly are more likely to experience early childbirth,
miscarriage, and other pregnancy complications. Using a douche can also lead to an
ectopic pregnancy, and women who use douches may have a difficult time getting
pregnant.
- Infections like PID, Cervicitis, Vaginosis.
A healthy balance of bacteria prevents vaginal yeast from overgrowing. Eliminating
the natural balance may let yeast flourish. This can lead to a yeast infection.
Likewise, a woman who douches is five times more likely to develop bacterial
vaginosis. Some women use douches hoping that washing the vagina will eliminate a
vaginal infection. Douching may make an infection worse. Douching while having a
vaginal infection may also spread the infection to other parts of the reproductive
system.
 योधनदाहन (Cervical Cauterization)
योतनदा न is the therapeutic procedure of burning vitiated tissue cells in the cervical area.
 पयािय = अतिकमब
 अधिष्ठान = तििीयाविब
 द्रव्य = शलाका
 औषि = सुवर्णब शलाका, औषध शलाका
(लोध्र, खदीर, तत्रफला, आमलकी, गुग्गुलु, तनम्ब, अशोक, etc.)
 मात्रा = Q.S.
 पररमाण = Until burnt tissue has greyish colour; repeat after 1-2 months
 काल = Morning

▪ Separate procedure room, clean table

▪ Vaginal speculum is inserted to visualize the cervix.
▪ Cervix is cleansed with sterile cotton swab.
▪ शलाका is ignited and placed carefully on vitiated tissue only.
▪ Tissue is burnt until greyish.
3) पश्चािकमब ▪ Patient should remain in supine position for 15-20 minutes.

▪ Vaginal discharge will be increased for 15 days because burnt tissue
cells will be expelled gradually.
▪ Rest for one day.
 उपद्रव = Severe burning sensation, Increased pain, Destruction of healthy

tissue, Non-healing ulcer formation
Pacification of Vata & Kapha Dosha due to Ushna, Tikshna, Sukshma & Ashukari
Guna. The vitiated tissue cells are burnt so that the old cells will be discharged and
proper new cells can develop. The applied heat also removes obstructions in the
Srotas and increases the blood circulation to the affected site which supports new
cellular growth.
 Cervical Cauterization
Cervical cauterization is a procedure used in surgery to remove unwanted or harmful
tissue. It can also be used as a counter-irritant as a haemostatic to burn and seal blood
vessels or as a means of destroying tumors.
 Method:
The woman lies in lithotomy position. Vaginal speculum is inserted into the vagina to
visualize the cervix. The cervix is cleansed using a saline vaginal swab. The vagina and
cervix are carefully examined for sings of inflammation or abnormal surface patterns.
To allow visualization of abnormal surfaces, a solution of acetic acid is applied to the
cervix. The acetic acid turns precancerous and cancerous regions of the cervix white
(aceto-whitening). A surface anesthetic or cervical nerve block may be administered
and cauterization is performed on the abnormally appearing regions.
 Electro-Cauterization: It is a procedure to remove unwanted or harmful tissue by

using heat conduction from a metal probe heated by electric current. It can also be
used to burn and seal blood vessels, which helps to reduce or stop bleeding.
 Cryo-Cauterization: The eroded tissue is necrotized by extreme coldness produced

by liquid carbon dioxide.
 Chemical Cauterization: It is a process where the chemical reactions can destroy

tissue. It is used to treat cervical cysts, precancerous erosion of the cervix and
cervicitis. The area to be cauterized must be dried by using a cotton swab to prevent
the chemical from trickling on to normal tissue.
A cotton swab moistened with the chemical cauterant (e.g. trichloracetic acid) is
touched to the cervical lesion. Cervical cysts should be punctured before application
of the cauterant. After a few minutes, the cauterized area is wiped with a dry swab to
remove any residual chemical.
 Laser Cauterization: It is an effective treatment for all cervical dysplasia including

those that are too large for cryo-cauterization and those that slightly extend into the
endocervix. It is carried out by aiming a carbon dioxide laser beam at the cervical
dysplasia. Because of the fine degree of control over the depth and width, the laser
can precisely vaporize the dysplasia while leaving adjacent normal tissue intact.
 Short-Wave Therapy: It aims to raise the temperature of deep seated tissues and to
induce hyperaemia. This in turn promotes natural resistance to infection and
encourages resolution of inflammatory processes as also the elimination of metabolic
waste products.
 Indications: Sub-acute and chronic cellulitis or salpingo-oophoritis; Early dysplasia;

Cervical erosion; Late radiation effects characterized by ischaemia of the tissues in
and around the vagia, uterus, bladder and rectum.
 Contraindications: Pregnancy, Presence of active infection, Suspected malignancy

 क्षारकमि
क्षारकमब is a surgical topic. It is included under the heading of Anushastra along with
Agnikarma and Jalauka-avacharana.
क्षर्णन means destruction of vitiated tissues; the therapeutic procedure by which this is
achieved is termed as क्षारकमब .
 प्रयोग = व्रर्ण, ग्रस्ि, अर्ुबद, योन्यशब, शोफ, र्ीजदोष, आिब वव्यापद् , योतनव्यापद्
 द्रव्य = क्षारोदक, क्षारवतिब , क्षारतपिु
क्षारोदक -> Kshara is dissolved in 6 parts of water and filtered for 21 times.
The obtained liquid is termed as क्षारोदक. It can be used as Parisheka in Kaphaja
Shopha, Krimi, Kaphaja Yonivyapad, etc.
क्षारवधति -> Churna of Daruharidra should be triturated with water for 15 days; then it
is dried in the sun. Snuhi & Arka Ksheera is added and it is further triturated until it
reaches the proper consistency to form Varti. It can be used in Bhagandara and
Nadivrana.
क्षारधपिु -> Ksharapichu has not been mentioned in the classical Ayurvedic textbooks.
A lot of research is done at Dept. of Shalya Tantra in BHU Varanasi.
Kshara is applied on a cloth in paste form, dried and Pichu is made to be applied in
the vagina.
 Benefits of Kshara:
- Kshara is Katu rasa, Ushna veerya, Tikshna and generally Agneya pradhana.
- It alleviates Tridoshas and can even be used on Marma-sthana.
- It does following actions: Dahana, Pachana, Darana, Vilayana, Shodhana, Ropana,
Shoshana, Lekhana, Bhedana, Chedana, Krimighna, etc.
CHAPTER III: Shalya tantra
 Dilatation and Curettage (D&C)

Dilatation and curettage refers to the dilation (widening/opening) of the cervix and
surgical removal of part of the lining of the uterus and/or contents of the uterus by
scraping and scooping(curettage).
 Diagnostic Indications: AUB, DUB, Endometrial Polyps, Endometrial hyperplasia,

Post-menopausal bleeding, Suspected pelvic tuberculosis, Suspected endometrial
cancer
 Therapeutic Indications: Miscarriage, Abortion, DUB, Infertility, Along with

polypectomy, Removal of embedded, IUCD, Ectopic pregnancy
 Contraindications: Suspected pregnancy, Infections: local or pelvic i.e. cervicitis,

endometritis, salpingitis
 Instruments: Swab holder, Sim’s speculum, Anterior vaginal wall retractor, Vulsellum,
Uterine sound, Cervical dilators, Curette, Uterine dressing forceps
 Procedure:
• Pre-medication: Inj. Atropin 0.6 mg I/M
• Emptying bladder
• Lithotomy position
• Painting & draping
• Short G/A is preferred.
• Expose cervix by speculum & ant. Vaginal wall retractor.
• Swab out cervix.
• Catch anterior lip of cervix by vulsellum
• Sounding of uterus
• Dilatation by well lubricated cervical dilators is done in increasing no. gradually.
• Sterile gauze piece is kept over the speculum below cervix for collection of curetted
material.
• Curette is introduced, passed up to the fundus & cavity is curetted in longitudinal
direction from fundus to the internal os.
• Start at 12 o’clock & work around the cavity in clockwise or anticlockwise direction.
• Curetting is done till grating sensation is felt.
• Material is collected for histopathology in a container having 10% formalin solution.
• Uterine cavity is cleaned.
• Instruments are removed.
• Check bleeding
• Vagina is cleaned & sterile pad is applied.
 Complications:
- Spreading infection
- Adverse reaction to general anesthesia
- Uterine perforation
- Laceration or tear of the cervix
- Haemorrhage
- Intrauterine adhesions due to vigorous curettage leading to secondary
amenorrhoea, or Asherman's syndrome (late complication)
Asherman's syndrome (AS), is an acquired uterine condition that occurs when scar
tissue (adhesions) form inside the uterus and/or the cervix.
 Surgical Sterilization
Sterilization is a procedure which permanently destroys the procreative function of an
individual.
1) Male -> Vasectomy
2) Female -> Tubectomy / Tubal ligation / Tubal Occlusion
Vasectomy
- Vasectomy is the permanent contraceptive method for males.
- It is a minor surgical procedure to prevent sperms from reaching the semen that is
ejaculated. It is done by bilateral vas ligation. After the procedure, semen still exists, but
is devoid of sperms. Testes will still produce sperms, but they will be soaked up by the
body. Also, the acceptor is not immediately sterile after the operation, usually only after
15-20 ejaculations have taken place.
- Vasectomy may be done in a urologist’s office, surgery center or hospital.
 Procedure:
i) Shaving of scrotal area
ii) Local anesthesia
iii) Transverse incision (1 cm) is made at the junction of the upper and middle third of
the median raphe and the vas deferens is exposed.
iv) The vas is cut and the ends are ligated, folded back on themselves and sutured
into portion so that the cut ends face away from each other to prevent
recanalization.
v) The same procedure is done on the other side.
 Post-operative Instructions:
- Strenous exercise should be avoided for at least two days.
- The patient can return to normal routine after one week.
- Srotal support should be used to reduce pain.
- It is necessary to use an alternative contraceptive method for the next 15-20
ejaculations.
 Complications:
- Haematomas
- Wound infection
- Sperm granulomas
- Late recanalization
- Anesthesia hazards
Tubectomy / Tubal Ligation
- Tubectomy is the permanent contraceptive method for females.
- It is a major surgical procedure in which the two fallopian tubes get disconnected to
prevent transport of eggs from the ovaries to the uterus.
- The most common procedures are:
1) Laparotomy
2) Mini-LAP (Mini-laparotomy)
3) Laparoscopic Sterilization
1) Laparotomy
It is the traditional approach for tubectomy.
 Procedure:
i) Anesthesia – general, spinal or local
ii) The patient is made to lie in lithotomy position after voiding urine.
iii) Abdomen is painted and draped.
iv) Abdomen is opened in layers by sub-umbilical incision.
v) Fallopian tube is visualized and grasped by Babcock’s forceps; its loop is brought
out. The frimbiral end is identified to confirm the tube.
vi) A loop of the ampullary or isthmic region is selected where the mesosalpinx is less
vascular and is crushed with the artery forceps. It is ligated with non-absorbable
suture. The loop is excised and the stump is inspected for any bleeding.
vii) The same is repeated on the other side.
viii) The stumps are left inside and the abdomen is closed in layers.
2) Mini-LAP (Mini-laparotomy)
It can be done during postpartum, post-abortal or interval period.
 Procedure:
i) The patient is operated on empty stomach, empty bladder under local anesthesia.
ii) Premedication: Promethazine or mepiridine I.M. is given along with mild sedation,
if necessary.
iii) Patient is made to lie in lithotomy position after voiding urine.
iv) Abdominal incision: The abdomen is opened by 2-3 cm sub-umbilical incision.
2 cm below fundus in postpartum cases. In interval mini-LAP, the abdomen is opened
2-3 cm transvere suprapubic incision 2.5 cm above symphysis pubis.
v) The cervix is grasped with tenaculum forceps and uterine elevator is introduced to
elevate the uters against the anterior abdominal wall. In postpartum cases, the
uterus is an abdominal organ; hence uterine elevator is not needed.
vi) The tubes are identified by the frimbriated end and ligation is done by Pomeroy’s
technique or occluded by rings or clips.
vii) The same procedure is repeated on the other side.
viii) The stumps are left inside and the peritoneum is sutured. The abdomen is closed
in layers.
ix) The patient is discharged after 4 hours of observation.
3) Laparoscopic Sterilization
Laparoscopic sterilization is becoming increasingly popular as the stezilizing effect is
nearly as certain as surgical resection of the tubes and it is appealing to the patient as
they can return home sooner, the post-operative pain and discomfort is less, and there is
a cosmetic advantage. However, it is less economical and it should only be done when
the uterus is a pelvic organ.
 Procedure:
i) It can be done under local anesthesia with sedation or general anesthesia.
ii) Creating a pneumoperitoneum: A small skin incision (1.25 cm) is made just below
the umbilicus. Verres needle is introduced through the incision with 45° angulation
into peritoneal cavity. Abdomen is inflated with 1-4 litre of gas (CO2).
iii) Trocar introduction: Abdominal wall is elevated and the trocar with cannula is
inserted through same incision.
iv) Laparoscope is introduced into the peritoneal cavity. The internal genital organs
are inspected.
v) A second puncture is done. A stab incision is taken.
vi) Trocar and cannula for the ring applicator is thrust into the peritoneal cavity
through the 2nd stab incision under direct vision through laparoscope to avoid injury
to other viscera.
vii) The uters and tubes are manipulated into convenient position by uterine elevator
through the cervix or by a probe from above.
viii) A portion of each tube, with its inner margin 1 cm from the cornua of the uterus,
is coagulated with diathermy and divided, or clips or rings are applied.
ix) The ring applicator is withdrawn and the laparoscope is removed.
x) Air inside the peritoneal cavity is removed, mandrel and trocar is removed.
 Post-operative Instructions:
- No exercise and complete rest for 3-4 days.
- No sexual intercourse for at least one week.
- Anaglesics may be given if necessary.
-> Caesarean Ligation: When tubal ligation is carried out along with caesarean section, it
is called caesarean ligation.
-> Tubal Occlusion: Female sterilization by tubal occlusion is a permanent procedure

where a micro-insert is placed into each of the fallopian tubes. The micro-inserts work
with the body to form a natural barrier that keeps sperm from reaching the eggs,
preventing pregnancy.
 Hysterectomy
(Garbhashaya Nirharana)
A hysterectomy is major operation to remove a woman’s uterus.

It is carried out to treat various problems associated with periods, pelvic pain, tumors
and other related conditions. Some conditions which have no alternatives might include
cancer, unbearable pain and bleeding.
 Indications:
- AUB, DUB; common causes are hormonal imbalances, fibroids, polyps, infections of
the cervix and cancer. Related symptoms may include heavy or long periods, bleeding
between periods or bleeding after menopause.
- Uterine fibroids (myomas); larger fibroids can press against the pelvic organs and
may cause bleeding, dyspareunia, anemia, pelvic pain, bladder pressure.
- Endometriosis, Adenomyosis, Uterine prolapse
- Bilateral chronic pelvic inflammatory diseases not responding to conservative
treatment.
- Endometriosis, fibroids, adhesions, infections or injury may be a few causes for
pelvic pain.
- Endometrial or Cervical cancer; Ovarian tumors; Endometrial hyperplasia
 Types:
1) Complete or total hysterectomy; removes the uterus, including the cervix. The
ovaries and fallopian tubes remain.
2) Partial or subtotal hysterectomy; only removes the upper part of the uterus and
leaves the cervix and other organs in place.
3) Panhysterectomy; total with bilateral salpingo-oophorectomy. Both tubes and
ovaries are removed.
4) Radical hysterectomy; removes the uterus, the cervix, the upper part of the
vagina, supporting tissues and usually the pelvic lymph nodes. This operation is
usually performed to treat cancer.
 Routes:
1) Abdominal
2) Vaginal
3) Laparoscopic
 Time of Surgery: Postmenstrual phase is preferred as there is less congestion, hence

less operative oozing.
 Investigations:
ABO-Rh, Haemogram, RFT, LFT, PPBS, U-R & M, Pap smear, ECG, X-ray chest, HIV,
HbsAg
 Pre-operative:
1. Admission before 12 hours of operation
2. Informed written consent
3. NBM (nil by mouth) for minimum 6 hours
4. Part preparation (vulva, back, abdomen) & vaginal painting
5. Sedative on night before operation
6. Enema in the morning
7. One bottle of blood should be kept cross matched & ready
8. Antibiotics 2 hours before
9. Foley’s catheter is introduced
10. Anesthesia: General, Spinal, Epidural
-> Abdominal Hysterectomy
 Instruments: Sponge holders, Scalpel blade no. 22, Dissecting forceps (toothed &
plain), Artery forceps (straight & curved), Kocher’ s clamps (straight & curved), Allis
forceps, Needle holders, Curved cutting, Round body needles, Bladder retractor
(large & small), Self-retaining abdominal retractor, Right angle retractor
 Steps of Operation:
1) Opening of abdomen
2) Removal of uterus
3) Closure of vaginal vault
4) Closure of abdomen
 Removal of uterus:
- After opening the abdomen, the parietes are retracted with self-retaining retractor.
- Bladder is retracted with bladder retractor.
- Uterus, tubes, ovaries & other pelvic organs are inspected.
- Pedicles are clamped, cut between the kocher’s forceps & ligated.
Pedicles:
- Pedicle 1 -> round ligament
- Pedicle 2 -> ovarian ligament & fallopian tubes at the cornue of uterus (if ovaries
are to be retained); infundibulo-pelvic ligaments (if ovaries are to be
removed)
- Uterovesical pouch of peritoneum is opened.
- Urinary bladder is pushed below the level of cx.
- Remaining 2 pedicles are cut between the clamps & ligated.
- Pedicle 3 -> uterine vessels
- Pedicle 4 -> uterosacral & mackenrodt’s liganents
- Vagina is opened & uterus is removed.
- Vagina is closed
- Pelvic peritonium is closed
- Closure of abdomen
 Post-operative:
- Maintain nutrient & hydration by parenteral fluid therapy for 24 hours
- 24 hours complete bed rest
- 2nd day: advice early ambulation
- Check bowel & urine output regularly
- Oral feeds only after peristalsis movements
- Suitable antibiotics
- After 8 days; the stitches are removed
 Complications:
- Problems related to the anesthesia
- Blood clots in the veins can break off and travel to the lungs.
- Injury to internal organs (urinary tract, bladder or bowel) and the skin
- Infection, Bleeding, Loss of ovarian function, Intestinal hernia
-> Vaginal Hysterectomy
 Advantages:
- Less operative discomfort & pain
- Less overall morbidity
- No scar related complication
- Vaginal wall prolapse can be corrected adequately
- Less incidence of abdominal distension, peritonitis, deep vein thrombosis &
embolism.
 Disadvantages:
- Less suitable hysterectomy
- Other abdominal viscera cannot be explored
- Infectious morbidity is slightly more due to vaginal bacterial flora
- Removal of ovaries is difficult
 Indications:
- All cases of genital prolapse
- Small fibroids
- Cervical premalignant lesion
 Contraindications:
- Uterine or ovarian tumors
- Nulliparous patient with no cervical descent
- Severe adhesions in pelvis
- Inexperienced surgeons
 Instuments:
In addition to general instruments; Sim’s speculum, Vulsellum, Right angle retractor,
Vaginal self-retaining retractor, Bladder sound, Catheter
 Steps of Operation:
1) Lithotomy position, Painting & drapping, Foley’s catheter introduced
2) Sim’s speculum is inserted into vagina
3) Cervix is held by vulsellum
4) Bladder is ascertained by bladder sound
5) Anterior vaginal wall is incised transversely below the bladder sulcus on the Cx
6) Incision is extended posteriorly in a circular manner
7) Vagina is separated posteriorly
8) Pouch of douglas is identified & opened, retract the rectum
9) Anteriorly, vesico-cervical ligament is incised & urinary bladder is pushed high up
10) Vesico-uterine pouch of peritoneum is identified & opened
11) Urinary bladder is retracted behind the right angle retractor
Pedicles: Clamp, cut, transfixed

- Pedicle 1 -> Uterosacral & mackenrodt’s ligaments
- Pedicle 2 -> Uterine vessels
- Pedicle 3 -> Round ligaments & fallopian tubes
- Peritoneum is sutured & pedicles are extraperitonized.

- All the pedicles from either side are brought together in the midline.
- Vaginal edges are approximated.
- Tight pack may be kept in the vagina for 6-12 hours.
 Complications:
1) Intra-operative: Haemorrhage, Injury to urinary bladder or rectum, anesthetic
complications
2) Post-operative: Retention of urine, Urinary infection, Pelvic infection
3) Delayed: Vault prolapse, Vault granulation
 Myomectomy
Myomectomy is a surgical procedure to remove uterine fibroids, also called leiomyomas.
 Indications:
- Sub-mucous fibroid interfering with infertility
- Intramural fibroids distorting the uterine cavity
- Pedunculated fibroid undergoing torsion
- Greater than 5-7 cm
- Patients with uterine fibroid having recurrent abortion
- Fibroid situated in lower part of uterus and likely complicating delivery
- Persistent uterine bleeding
- Excessive pain or pressure symptoms
- Rapidly growing myoma
- Infected fibroid
- Growth of myoma after menopause
- Suspected malignant changes
- Functionless fallopian tubes
- Pelvic or endometrial TB
 Complications:
1) Immediate:
- Haemorrhage
- Injury to bladder and ureter
- Injury to fallopian tube
- Injury to bowel
- Febrile morbidity
2) Remote:
- Risk of recurrence and persistence of fibroid is 30-50%.
- Risk of persistence of menorrhagia is about 1-5%.
 Procedure:
• A single incision in the midline on anterior wall of uterus is given.
• Incision is deepened through myometrium till myoma is reached.
• Myoma is grasped with a single toothed vulsellum and dissection is continued.
• Myoma is enucleated from its bed by sharp and blunt dissection.
• Myoma bed is obliterated by interrupted mattress sutures.
Bony Hood Operation

• It is done to remove fundal myoma.
• Low transverse incision is made on myoma over anterior uterine surface.
• After enucleation of myoma, capsule is trimmed and sewn over anterior uterine
wall.
Cervical Fibroid
Anterior Cervical Myoma:
• Transverse incision is made over uterovesical peritoneum.
• Bladder is dissected down.
• Fibroid is then enucleated.
Posterior Cervical Myoma:

• Low posterior incision on uterine surface through POD.
Central Cervical Myoma:

• Peritoneum of uterovesical pouch is incised transversely and bladder is dissected
down.
• Then myoma is enucleated.
 Pessaries
A pessary is a prosthetic device that can be inserted into the vagina to support its
internal structure.
It is often used in case of urinary incontinence and vaginal or pelvic organ prolapse. A
prolapse occurs when the vagina or another organ in the pelvis slips out of its usual
place. The support a pessary provides can help a woman avoid pelvic surgery.
This device can also be used as a vessel for administering medication slowly.
A pessary needs to be fitted by a medical professional as they can cause vaginal damage
and fail to improve symptoms if fitted incorrectly. A collapsed pessary is inserted into the
vagina and put in place just under the cervix. Depending on the type of pessary used, it
may be inflated using a bulb.
 Types:
There are two main types of pessary:
1) Support
2) Space-filling
They are available in many different shapes and sizes to fit a woman’s individual
anatomy. They are usually made from medical-grade silicone, which makes them
durable and resistant to absorption.
The most commonly used support pessary is the ring pessary with support. This is
because it fits a large majority of women and can be used at all stages of pelvic organ
prolapse.
The most commonly used space-filling pessary is the Gellhorn pessary. This has a
broad base with a stem that comes in different lengths so that it will also be able to
fit most women.
 Endometrial Biopsy (EB)
An endometrial biopsy is the removal of a small piece of tissue from the endometrium,
which is the lining of the uterus.
This tissue sample can show cell changes due to abnormal tissues or variations in
hormone levels.
A biopsy can also check for uterine infections such as endometritis.
An endometrial biopsy may be performed to help diagnose abnormalities of the uterus.
It can also rule out other diseases.
 Indications: Abnormal menstrual bleeding, Bleeding after menopause, Absence of

uterine bleeding, Evaluation of fertility
 Contraindications: During pregnancy, Blood clotting disorder, Acute pelvic

inflammatory disease, Acute cervical or vaginal infection, Cervical cancer, Cervical
stenosis
 Procedure:
• With or without local anesthesia
• Lithotomy position
• Visualization of cervix by speculum
• Clean cervix with an antiseptic solution
• Catch the cervix with vulsellum forceps
• The biopsy curette will be inserted into the uterine fundus and with a scraping and
rotating motion some tissue will be removed. The removed tissue will be placed in
formalin or equivalent for preservation.
• The tissue will be sent to a laboratory, where it will be processed and tested.
• It will then be read microscopically by a pathologist who will provide a histological
diagnosis.
 Complications: Cramps or pelvic pain, Uterine infection, Uterine perforation (rare)
 Interpretation of the Result:

- An endometrial biopsy is normal when no abnormal cells or cancer is found.
- Results are considered abnormal when:
a) Benign, or noncancerous, growth is present
b) Thickening of the endometrium, called endometrial hyperplasia, is present
c) Cancerous cells are present
 Cervical Biopsy
Cervical biopsy is a surgical procedure in which a small sample of tissue is removed from
the cervix. The sample is examined under a microscope; it is used for the diagnosis and
treatment of cervical cancer and precancerous conditions.
 Types:
1) Punch Biopsy
2) Wedge Biopsy
3) Ring Biopsy
4) Cone Biopsy (Conization)
5) Surface Biopsy (Pap smear for cytology)
1) Punch Biopsy
Biopsy is taken from the suspected
area using Punch Biopsy forceps.
2) Wedge Biopsy
It is done when definite growth is visible.
Steps:
a) Posterior vaginal speculum is introduced.
b) Anterior and the posterior lip of the cervix is held by Alley’s forceps.
c) With a scalpel, a wedge of tissue is cut from the edge of the lesion including
the healthy tissue for comparative histological study.
3) Ring Biopsy
Whole of squamo-columnar junction area
of the cervix is excised with a special knife.
4) Cone Biopsy
Both diagnostic and therapeutic purpose in
CIN.
Removal of cone of the cervix which
includes entire squamo-columnar junction,
stroma with glands and endocervical
mucous membrane.
Methods: Cold knife, CO₂ laser, Laser
diathermy loop
5) Surface Biopsy
Biopsy obtained by detaching cells from cutaneous or mucosal surface with a
spatula, cotton swab or brush used to diagnose cervical cancer.
 PAP Smear
“The Golden Standard for Prevention of Cervical Cancer”
PAP smear sampling of cervix involves scraping of cervical surface and a portion of non-
visualized cervical canal using various sampling devices.
 Guidelines for Preventive Screening:

- Age 21: Start screening if sexually active
- Age 21-30: Pap test every 3 years
- Age 31-65: Pap test every 3 years or co-testing (Pap & HPV) every 5 years
- Age 65: Stop screening (in low risk women with no history of severe dysplasia)
 Preparation of the Patient:

- Women should be tested two weeks after the first day of their last menstrual period
(day 14 of cycle is optimal)
- Women should not use any vaginal medication, contraceptives, etc. during the 48
hours prior to the sample collection.
- Sexual relationship is not recommended in the night before the test
 Procedure:
1) Precautions:
- Specimen should be obtained after inserting a non-lubricated speculum
(moistened only with warm water if needed).
- Excess mucous or other discharge should be removed gently with folded gauze
pad.
2) Pre-procedure:
- Inform and explain the procedure to the patient and get verbal consent.
- Advice the patient to empty the bladder.
- Provide privacy.
- Patient is placed in lithotomy position on the examination table.
- Drape the patient; permit minimal exposure.
3) Collection of Sample:
A) Vaginal smear
B) Cervical smear
C) Endocervical smear
Vaginal & Cervical Smear:
- Spatula is rotated through 360° maintaining contact with ectocervix.
- Do not use too much force [bleeding /pain]
- Do not use too less force [inadequate sample]
- Sample is smeared evenly on the slide and fixed immediately
Endocervical Smear:
- Endocervical sample is collected using an endocervical brush.
- Insert the cytobrush into the canal, so that last bristles of brush are visible.
- Rotate the brush through 180°[more rotations increase the chance of bleeding]
- Sample is rolled on the slide and fixed.
Fixation of Smear:
- Fixation is done immediately with a fixative such as 95% alcohol or cytofix spray
to avoid air drying.
- Spray should be kept at 10 inches, to avoid destruction of cells by propellant in
the spray.
4) Post-procedure:
- Observe for any discharge from the vagina
- Perineal care as needed
- Assist the patient from the lithotomy position to supine position
- Documentation
- Sent the specimen to the laboratory with the form
 Colposcopy
“Colpo” is a Greek word meaning vagina, “scopy” denotes looking/inspecting.
A colposcopy is a method of examining the cervix, vagina, and vulva with a surgical
instrument called a colposcope.
A colposcope is a large, electric microscope with a bright light that enables the doctor to
see the cervix more clearly under magnification.
The procedure is usually performed if the results of a Pap smear are unusual.
If any abnormal areas are found during colposcopy, a biopsy of the tissue is done. The
samples are sent to a lab for examination by a pathologist.
 Indications:
- To locate abnormal areas or growth
- To obtain a directed biopsy
- Abnormal Pap smear cytology
- Post-coital bleeding
- To diagnose abnormal cervical cells, precancerous or cancerous cells, genital warts
and cervicitis.
 Procedure:
The patient is placed in lithotomy position; cervix is exposed with a speculum and
colposcope is introduced focusing on the external os at a distance of about 20 cm.
The SQ junction is inspected before and after applying 3-5% aqueous acetic acid
solution. Acetic acid precipitates proteins and abnormal epithelium appears white.
Then the cervix is painted with Shiller’s iodine which differentiates darker glycogen
laden cells from paler glycogen free cells. Neoplastic tissue is devoid of glycogen and
therefore does not take up iodine stain.
A tissue sample is taken from the non-stained areas.
 Laparoscopy
Laparoscopy is a surgical procedure in which a fibre-optic instrument is inserted through
the abdominal wall to view the abdominal organs or perform a small-scale surgery.
It is a low-risk, minimally invasive procedure that requires only small incisions.
Laparoscopy uses an instrument called a laparoscope to look at the abdominal organs. A

laparoscope is a long, thin tube with a high-intensity light and a high-resolution camera
at the front. The instrument is inserted through an incision in the abdominal wall. As it
moves along, the camera sends images to a video monitor.
 Instruments: Veress needle, Electronic laparoflator (insufflator), Trocars,

Laparoscope, Camera equipment & light source, Forceps & scissors
 Procedure:
1) Patient is placed in lithotomy position
2) Creating a pneumoperitoneum: A small skin incision (1.25 cm) is made just below
the umbilicus. Verres needle is introduced through the incision with 45° angulation
into peritoneal cavity. Abdomen is inflated with 1-4 litre of gas (CO2).
3) Trocar introduction: Abdominal wall is elevated and the trocar with cannula is
inserted through same incision.
4) Viewing the peritoneal cavity.
5) After the procedure: CO2 gas must be evacuated completely to reduce post-
operative pain.
 Indications:
1) Diagnostic
2) Therapeutic
1) Diagnostic Laparoscopy
- Infertility work up
- Chronic pelvic pain
- Nature of pelvic mass
- Suspected acute pelvic lesion
- Suspected PID (Laparoscopy is the golden start to diagnose PID)
- Follow up of pelvic surgery
- Investigation protocol of amenorrhoea
- Suspected Mullerian abnormalities
- Suspected tubo-ovarian masses
- Oncologic procedures
- Ectopic pregnancy
2) Therapeutic Laparoscopy
a. Minor procedures: Tubal sterilization, Adhesiolysis, Aspiration of simple
ovarian cyst, Ovarian biopsy
b. Moderate procedures:
- Ectopic Pregnancy -> Salpingostomy, Segmental resection, Salpingectomy,
Salpingo-oophorectomy
- Endometriosis -> Ablation by diathermy or laser
- Ovary -> Diathermy for PCOS, Drainage of endometrioma, Ovarian
cystectomy, Salpingo-ovariolysis
- Uterus -> Myomectomy, Laproscopic assisted vaginal hysterectomy,
Adhesiolysis
c. Extensive Procedures:
Major endometriosis -> Myomectomy, Pelvic lymphadenectomy
- Generalized peritonitis
- Intestinal obstruction
- Severe cardiopulmonary distress
- Extreme obesity
- Patient is haemodynamically unstable
- Significant haemoperitoneum
- Extensive peritoneal adhesion
- Large pelvic tumor
- Pregnancy > 16 weeks
 Complications:
- Extra peritoneal insufflation
- Omental emphysema
- Cardiac arrhythmia
- Injury to blood vessels, bowel, ureter.
- Electrosurgical complication
- Gas embolism
Anesthetic Complications:
- Hypoventilation
- Hypercarbia and metabolic acidosis
- Basal lung atelectasis
- Esophageal intubation
- Aspiration
- Cardiac arrest
 Hysteroscopy
Hysteroscopy is an endoscopic visualization of the uterine cavity, tubal openings and
endocervix by means of a fibreoptic hysteroscope passed through the cervical canal.
It allows direct visualization inside the uterus.
It can be used for both diagnostic and therapeutic purposes.
 Indications:
1) Diagnostic hysteroscopy
- Abnormal uterine bleeding; Menorrhagia, Postmenopausal bleeding
- Infertility
- Müllerian abnormalities
- Recurrent miscarriage; intrauterine pathology such as fibroids, polyps
- Misplaced IUD
- Chronic pelvic pain due to fibroid, bicornuate uterus
- Visualization of the transformation zone
2) Operative hysteroscopy
- Polypectomy and myomectomy
- Intrauterine adhesion lysis
- Endometrial ablation in cases of DUB
- Endometrial resection; excision of the endometrium
- Metroplasty; resection of uterine septum.
- Retrieval of lost IUCD and foreign bodies
- Biopsy of suspected endometrium
- Tubal cannulation; in case of proximal tubal obstruction
- Tubal sterilization
- Pregnancy
- Pelvic infection; hysteroscopy can lead to spread of infection
- Cervical cancer; trauma to cervix can cause excessive bleeding
- Cardiopulmonary disorders; hysteroscopy has risk of gas embolism, fluid overload
and pulmonary oedema.
- Cervical stenosis
 Procedure:
The procedure should be done during post menstrual period in proliferative phase
from day 6-10.
Steps:
Anesthesia, Empty bladder, Lithotomy position, Aseptic and antiseptic precautions.
PV examination. Sounding uterocervical canal. Dilatation is done.
Distension of uterine cavity is made by distending media.
Sheath with obturator is introduced through dilated cervix and obturator is removed.
Hysteroscope is introduced and uterine cavity is systematically viewed.
 Hysterosalpingography (HSG)
Hysterosalpingography, also known as uterosalpingography, is an operative procedure to
assess the interior anatomy of uterus and tubes including tubal patency.
 Indications:
- To note tubal patency in investigation of infertility; complete or partial tubal block;
site of the block.
- To detect congenital malformations of uterus.
- To identify translocated IUCD.
- To diagnose cervical incompetency.
- Follow up evaluation of tuboplasty.
- To confirm the diagnosis of secondary abdominal pregnancy.
Uterine Pathology: Uterine anomaly, Fibroid, Adenomyosis, Endometrial polyp,

Intrauterine adhesions, Endometrial TB, Cervical incompetence
Tubal Pathology: Tubal block, Tubal spasm, Tubal polyp, Hydrosalpinx, Salpingitis
isthmic nodosum (SIN), Peritubal adhesions, TB salpingitis
 Procedure:
- Patient is placed in dorsal position.
- Posterior vaginal speculum is introduced, anterior lip of cervix is held by Allis
forceps and uterine sound is passed.
- HSG cannula is fitted with a syringe containing radiopaque dye; dye is introduced
slowly.
- The speculum and Allis forceps is removed but not the cannula.
- Radiographic views are taken.
 Complications:
- Pain (because of dilatation of uterus, spillage into peritoneum)
- Infection (pelvic)
- Bleeding
- Vascular or lymphatic intravasation
- Vasovagal episode
- Allergic reaction (to iodinated contrast media)
 Ultrasound (US) / Ultrasonography (USG)
An ultrasound is a tool used to take a picture. A sonogram is the picture that the
ultrasound generates. Sonography is the use of an ultrasound tool for diagnostic
purposes.
Ultrasound is an imaging technology that uses high-frequency sound waves to

characterize tissue. It is a useful and flexible modality in medical imaging, and often
provides an additional or unique characterization of tissues, compared with other
modalities such as conventional radiography or CT.
Ultrasound waves; i.e. high-frequency sound waves ranging between frequencies of
2.5-7.0 megahertz are used.
It is considered to be a safe, non-invasive, accurate and cost-effective investigation for
evaluation during pregnancy and of gynecological pathology.
 Advantages:
- Ultrasound uses non-ionizing sound waves and has not been associated with
carcinogenesis. This is particularly important for the evaluation of foetal and gonadal
tissue.
- In most centers, ultrasound is more readily available than more advanced cross-
sectional modalities such as CT or MRI.
- Ultrasound examination is less expensive to conduct than CT or MRI.
- There are few contraindications to the use of ultrasound, compared with MRI or
contrast-enhanced CT.
- The real-time nature of ultrasound imaging is useful for the evaluation of physiology
as well as anatomy (e.g. foetal heart rate).
- Ultrasound images may not be as adversely affected by metallic objects, as opposed
to CT or MRI.
- An ultrasound exam can easily be extended to cover another organ system or
evaluate the contralateral extremity.
 Disadvantages:
- Training is required to accurately and efficiently conduct an ultrasound exam and
there is non-uniformity in the quality of examinations.
- Ultrasound is not capable of evaluating the internal structure of tissue types with
high acoustical impedance (e.g. bone, air). It is also limited in evaluating structures
encased in bone.
- The high frequencies of ultrasound result in a potential risk of thermal heating or
mechanical injury to tissue at a microscopic level. This is of most concern in foetal
imaging.
- Some ultrasound exams may be limited by abnormally large body habitus .
 Transvaginal Ultrasound (TVUS)
A transvaginal ultrasound, also called an endovaginal ultrasound, is a type of pelvic
ultrasound used to examine female reproductive organs. This includes the uterus,
fallopian tubes, ovaries, cervix, and vagina.
“Transvaginal” means “through the vagina.” This is an internal examination.
Unlike a regular abdominal or pelvic ultrasound, where the ultrasound wand (transducer)
rests on the outside of the pelvis, this procedure involves inserting an ultrasound probe
about 2 or 3 inches into the vaginal canal.
 Indications:
- Pelvic abnormalities, Pelvic pain
- Unexplained vaginal bleeding
- Infertility
- Cysts, Uterine fibroids
- Verification that an IUD is placed properly
- Ectopic pregnancy
- To monitor the heartbeat of the foetus
- To look at the cervix for any changes that could lead to complications such as
miscarriage or premature delivery.
- To examine the placenta for abnormalities
- To diagnose a possible miscarriage
- To confirm an early pregnancy
 X-Ray
X-rays are electromagnetic radiation that differentially penetrates structures within the
body and creates images of these structures on photographic film or a fluorescent
screen. These images are called diagnostic X-rays.
Diagnostic X-rays are useful in detecting abnormalities within the body. They are a
painless, non-invasive way to help diagnose problems such as broken bones, tumors,
dental decay, and the presence of foreign bodies.
Concerns about the use of X-ray procedures during pregnancy stem from the risks
associated with foetal exposure to ionizing radiation. The risk to a foetus from ionizing
radiation is dependent on the gestational age at the time of exposure and the dose of
radiation. If extremely high-dose exposure occurs during early embryogenesis, it most
likely will be lethal to the embryo. However, these dose levels are not used in diagnostic
imaging.
INSTRUMENTS
 Sim’s Vaginal Speculum

- Designed by James Marion Sim.
- Synonyms: Duck-bill speculum, Double blade posterior vaginal wall speculum, Sim’s
posterior vaginal wall retractor
- It is used to retract the posterior vaginal wall.
- The blades are unequal in breadth. Generally, the small blade is used in nulliparous; the
large blade in multiparous.
 Indications:
- To examine the anterior vaginal wall and cervix.
- To examine cervix and vagina for discharge, cervicitis, polyps, prolapse, carnioma,
uterine malformations.
- To carry out biopsy, Pap smear, D & C, HSG, Hysteroscopy, Vagina hysterectomy,
Polypectomy, Coptomy / Culdocentesis, Anterior colporrhaphy, etc.
- To examine tears.
- To insert or remove IUCD.
 Disadvantage: It is non-self-retaining.
 Sim’s Triad:
1) Sim’s speculum
2) Sim’s position
3) Sim’s VVF repair surgery
 Cusco’s Speculum
- Synonym: Cusco’s bivavled self-retaining vaginal speculum
- It is used to retract the anterior and posterior vaginal walls.
 Indications:
- Cervical and vaginal inspection
- Pap smear, Cervical biopsy, Colposcopy, Colpomicroscopy
- Cervico-vaginal swab, Gram stain culture
- To insert or to remove IUCD or to inspect the threads.
 Disadvantage:
- Anterior & posterior vaginal wall cannot be examined.
- Less space available and therefore not useful for minor or major gynecological
surgeries done through the vagina.
 Sim’s Anterior Vaginal Wall Retractor
- It is used to retract the anterior vaginal wall.
- It has spoon-shaped ends with transverse serrations and the loop makes anangle of 15°
with the shaft.
 Indications: (Same as Sim’s speculum)

- To elevate the anterior vaginal wall during inspection of cervix in case of cystocele.
- Retraction of anterior vaginal wall in conjunction with Sim’s speculum.
 Uterine Curette
- It has a central shaft, one sharp end and one blunt end. It is available in 3 sizes. The
loops are of vaious sizes -> Small (4 mm), Medium (6 mm), Large (8 mm).
The blunt end is used in pregnant uterus or when the uterus is soft to avoid perforation
or cellular metastasis; the sharp end is used in non-pregnant uterus.
 Types:
- Sharp at one end, blunt at the other end
- Sharp or blunt at both ends
- Handle with only sharp at one end
- Flushing curette (blunt)
- Sharman’s curette
 Indications: Curetting the endometrium for HPE

sample or therapeutic purpose:
- DUB
- Diagnosis of endometrial CA and endometrial TB
- Infertility: Premenstrual sample of endometrium
- Fothergill’s operation
- Manipulation of uterus during laparoscopy
- After evacuation of H. mole
- After D & C in 1st trimester MTP
 Endometrial Biopsy Curette

- Synonym: Duncan curette
- Slender, tubular, blunt ended and slightly curved at the tip to
facilitate entry into the endometrial cavity.
 Indications:
- Diagnosis of DUB, infertility, endometrial carcinoma
- Endometrial dating to diagnose anovulation
- It can act as uterine sound.
 Cervical Dilators
Hegar’s Cervical Dilators: They are long rod-like structures
with tapering double end with difference of 1 mm between
the ends and a gentle curve. There are 12 sets; smallest is 1-2
mm. They are numbered as per the outer diameter.
Hawkin Ambler Cervical Dilators: There are 16 sets starting

from 3/6 mm to 18/21; 3/6 mm means 3 mm at the tip of the
dilator and 6 mm at the base. They are angled at 2.5 inches
from the tup indicating the normal length of uterocervical
canal.
 Indications:
- D&C, D&E
- Manchester / Fothergill’s procedure
- Hysteroscopic procedures
- Drainage of uterine fluids
- Palmer’s test for incompetent os
- Shirodkar’s test for incopmpetent os
- Cervical stenosis
- To treat primary dysmenorrhoea
- IUCD insertion or removal
- Application of intrauterine radium in brachytherapy
 Complications: Tears, Haemorrhage, Perforation, Infection
 Uterine Sound
- Designed by Simpson.
- 12” long and marked in inches.
- Blunt rounded tip. The uterine end is curved and angulated.
 Indications:
- To measure length of cervical canal and diagnose supra-
vaginal elongation of the cervix.
- Length and direction of uterus.
- To diagnose and differentiate a polyp lying in cervix.
- To differentiate polyp and inversion.
- Locating misplaced IUD.
- Correction of mobile retroversion of uterus.
 Sponge Holding Forceps
This forceps is 22.5 cm long, straight
with a lock. It has ring-shaped ends with
transverse serrations on the inner
surface to prevent slipping.
 Indications:
- Preparation of vagina, vulva, and
abdominal wall before surgery.
- It is an atraumatic clamp to hold the pregnant cervix during repair of cervical tears.
- To hold cervix during cerclage.
- To hold cervix during insertion of Foley’s catheter in 2nd trimester for termination
using ethacridine lactate.
- Post-partum IUCD insertion
- Uterine packing in PPH
- Removal of retained placental tissue
- Holding the cut ends of lower segment during
LSCS.
 Ovum Holding Forceps

The blades have spoon-shaped blunt fenestrated
ends. Anything held in the blades is firmly caught.
It causes minimal trauma to the uterine wall if
caught and has no crushing effect on the conceptus.
 Indications:
- Used to remove retained products of
conception or placenta.
- Used to remove the molar tissue in case H. mole.
- Used to remove uterine polyp.
 Uterine Dressing Forceps

The blades have transverse serrations.
 Indications:
- Used to swab the uterine cavity with sterile gauze
and antiseptics in D & E operation.
- To dilate the cervix in case of pyometra or
lochiometra.
- Uterine packing during PPH or to plug the uterine
cavity with gauze twigs in continuous bleeding after
removal of polyp.
 Vulsellum (Multiple Toothed)
This instrument is 8” long and is usually curved. It has a shapr teeth
at the end, with interlock and gives a firm grip. It is ued to hold and
steady in various gynecological operations.
 Indications:
- To hold the anterior lip of cervix in D&C, anterior
colporrhaphy, vaginal hysterectomy.
- To hold the posterior lip of cervix in posterior colpotomy.
- Manchester repair
- To hold the fundus during abdominal hysterectomy.
- To remove polyps.
- Used in destructive operation especially in evisceration to have a good grip of foetal
parts for giving traction.
- Posterior lip is held in condition like amputiation of cervix, posterior colpotomy for
draining pus, culdocentesis, in case of malignant lesions on anterior lip.
 Tenaculum Forceps
Single toothed Vulsellum. It can offer a firm grip with
less cervical damage.
 Indications:
- Used to hold the left out cervical stump after
amputation of cervix or after subtotal hysterectomy.
- Used to hold the anterior lip of nulliparous cervix in
diagnostic and curettage.
- Used to hold the cervix after opening the vault of
the vagina to give traction while the remaining vault
is being cut in total abdominal hysterectomy.
 Artery Forceps
It is a hemostat forceps available in various sizes. There are 2
shapes; straight and curved.
 Indications:
- Used as a clamp in hysterectomy, salpingectomy, salpingo-
oophorectomy.
- Used for clamping bleeding vessels.
- Grasping tissue at the time of operation.
- Used while opening and closing peritoneum.
- Holding stay sutures.
 Allis Tissue Forceps
It may be long (17 cm) or short (12 cm). The blades are
curved at the ends and toothed 4 in 5 or 5 in 6 teeth.
 Indications:
- Holding cut ends of the vagina during
colporrhaphy, TAH, vaginal wall excision.
- Holding the peritoneum or rectus fascia while
opening and closing the abdominal wall.
- Holding the anterior lip of cervix during D&C,
cervical biopsy, HSG.
- Holding the uterine fundus during vaginal
hysterectomy.
- To catch the two torn ends of external anal
sphincter in repair of a complete perineal tear.
- Myomectomy, Polypectomy, Metroplasty
 Ayre’s Spatula
It is used for Pap smear for screening of cervical cancer. It is
made up of wood or plastic so that cells can adhere to its
porous surface during collection. The long projected end of
the spatula is placed at the ectocervix and rotated 360° to
collect cells from the entire ectocervix; the other end is used
for collection of vaginal cells from fornices for hormonal
status.
 Cytobrush / Endocervical Brush

The cytobrush is used to collect the cells from endocervical
canal for cytological screening.
CHAPTER IV: miscellaneous
 Garbhanirodhaka Upaya
Garbhanirodhaka Upaya are contraceptive methods.
 Bahya Prayoga:
1) Kalkadharana with Saindhava Lavana and Tila Taila prior to sexual intercourse.
2) Kalkadharana with Palasha Beeja and Ghrita.
3) Yonipurana with Dattura Mula.
4) Yonipichu with Nimba Taila.
5) Yonidhupana with Nimbi kasta.
6) Dattura Mula which is grown on Krishna Chaturdashi is tied around the woman’s
waist.
 Abhyantara Prayoga:
1) Pippali, Vidanga and Tankana should be taken during Ritukala.
2) Vidanga Churna with Udaka should be taken from 5th day to 15th day of
menstrual cycle.
3) Talisa Churna and Garikia with Udaka for 4 days during Ritukala.
4) Gunja Phala Churna with Tila Taila for 3 days during Ritukala.
5) Shveta Maricha with Sharkarodaka for 3 days during Ritukala.
6) Palasha Beeja Churna with Madhu for 3 days during Ritukala.
 Birth Control
Birth control, also known as contraception and fertility control, is a method or device
used to prevent pregnancy.
Planning, making available, and using birth control is called family planning.
 Methods of Contraception:
1) Temporary
i) Natural contraception
ii) Barrier method
iii) Intrauterine contraceptive devices (IUDs)
iv) Steroidal contraception
v) Emergency contraception (post-coital)
2) Permanent
i) Male sterilization -> Vasectomy
ii) Female sterilization -> Tubectomy / Tubal ligation
-> Refer to Chapter III, Surgical Sterilization
Natural Contraception
Failure rate -> 20-30 (HWY)
1) Fertility Awareness Methods

a) Calendar / Rhythm method
b) Basal Body Temperature (BBT) method
c) Cervical mucus
d) Symptothermal method
e) Test strips (high tech hormonal monitoring)
2) Coitus Interruptus
3) Lactational Amenorrhoea (LAM)
1) Fertility Awareness Methods

a) Calendar / Rhythm method
- Record the number of days for previous 6 menstrual cycles.
- Subtract 18 from the length of her shortest cycle -> 1st day of fertile period.
- Subtract 11 days from the length of her longest cycle -> last day of fertile period.
- Sexual intercourse is avoided during this period.
b) Basal Body Temperature (BBT) method

- Daily monitoring of temperature before getting up from bed.
- With ovulation, temperature rises by 0.4°F or more due to progesterone effect.
- Fertile period ends 3 days after temperature rise.
- Pre-ovulatory safe period is not detected.
c) Cervical mucus
Fertile period starts from the 1st day of any cervical secretions or feeling vaginal
wetness until the 4th day after peak day of slippery secretions.
d) Symptothermal method
- At least two indicators are used to identify the fertile period.
- BBT + Calendar Method / BBT + Cervical mucus
2) Coitus Interruptus (Withdrawal method)

During coitus, penis is withdrawn from vagina just before ejaculation.
3) Lactational Amenorrhoea (LAM)

Criteria for this method include:
i) Exclusive breast feeding
ii) Menstruation has not started
iii) Period up to 6 months postpartum
Barrier Contraception
Barrier method prevent sperm deposition in the vagina or prevent sperm penetration
through the cervical canal.
Advantages: Cheap, no side effects, protection against STD, PID, other infections
Disadvantages: May accidentally break, inadequate sexual pleasure, allergic reaction,

discard after one coital act. Failure rate -> 15 (HWY)
1) Mechanical
a) Male -> Condom
b) Female -> Condom, Diaphragm, Cervical Cap
2) Chemical (vaginal contraception)

a) Spermicides (Sperm immobilization)
b) Creams (Deleen – nonoxynol)
c) Jelly (Koromex, Volpar paste)
d) Foam tablets (Aerosol foams, Chloromin T, Contab)
3) Combination -> Comined use of Mechanical and Chemical methods.
-> Diaphragm
The device is introduced up to 3 hours before intercourse and is to be kept for at least 6
hours after the last coital act.
Disadvantages: Requires help of another person to measure the size; risk of UTI, vaginal
irritation; not suitable for women with uterine prolapse.
Intrauterine Contraceptive Device (IUCD)
1) Cu T 200
2) Cu T 380
3) Multiload 250
4) Multiload 375
5) LNG-IUS
Divided into 2 groups:

a) First generation-inert / unmedicated device
b) Second generation-bioctive / medicated device containing metals like copper, zink, silver
or containing hormones e.g. progestasert or containing drugs like tranexamic acid or
episilone aminocaproic acid.
1) Cu T 200
- Length = 36 mm
- Width = 32 mm
- Weight = 120 mg
- Diameter = 0.25 mm
- Surface area of copper = 200 sq mm
- It releases daily 50 μg of copper in during the first year. It is effective for 3 years.
2) Cu T 380
- The Government is now supplying this device.
- T shaped device with 2 solid copper sleeves on transverse arms & copper wire on the
vertical stem.
- Surface area of copper = 380 sq mm
- It is effective for 6-10 years.
Time of insertion:
- During menstrual period from 2nd day onwards or within 10 days of menstruation.
- Immediately after 1st trimester MTP or spontaneous abortion.
- Postpartum; after normal or preterm delivery it can be introduced immediately or at the
end of 6 weeks.
- At the time of caesarean section.
- Post-coital within 5 days of unprotected intercourse -> emergency contraception.
Advice to the patient:

- Patient should regularly check the thread by self examination & particularly after 1st
menstrual period.
- Inform -> increased bleeding, pain for first 2-3 months.
- Follow up -> after first menses & then yearly.
- Consult immediately in case of misseds period / any complications / thread cannot be felt.
- Replace when the time limit is over.
Mechanism of action of IUCD:
- It produces non specific biochemical and hystological changes in the endometrium.
- Ionized copper has got spermolytic and gametotoxic effects.
- Uniform suppression of the endometrium and it produces very scanty cervical mucous.
- Increased tubal mobility.
- Increased uterine contraction.
- Endometrial inflammatory response.
Indications of removal of IUCD: Excessive uterine bleeding. Flaring up of pelvic infection.

Uterine perforation. Pregnancy. Missing thread. Patient wants to conceive. Patient has
entered menopause.
Failure rate: Cu T 380 A -> 0.6 to 0.8 / HWY (3 to 8 / 1000)
Contraindications: Nulliparity, Suspected pregnancy, PID, DUB
Complications:
Immediate -> pain, syncopal attack, uterine perforation
Late -> pain, AUB, pelvic infection, spontaneous expulsion, perforation of the uterus, ectopic
pregnancy
Advantages: Simplicity in insertion. Return of fertility is immediate on removal of device.

Cheap (supplied by Govt.) It does not interfere with the sexual act. No systemic side effect.
No effect on breast milk. Less failure rate. Long term upto 10 years.
3-4) Multiload 250 / 375

- Shape is different from Cu-T. Side arms of T are bent with small outer projections.
- Copper surface area = 250/375 sqmm.
- Time limit = 3 years / 5 years
- Perforation & expulsion is less as compared to Cu-T.
5) LNG-IUS / LNG 20 – Mirena

- T shaped device with flexible arms. It has a capsule on the stem which contains a mixure of
silicone rubber & 60 mg levonorgestrel. Releases 20 mg/day.
- Time limit = 5 years
- It helps in treatment of DUB, fibroids, adenomyosis, endometriosis
- Failure rate = 0.1 to 0.2 / HWY
-> Replacement Time:

- Cu T 200 4 years
- Cu T 380A 10 years
- Multiload 250 3 years
- Multiload 375 5 years
- LNG-IUS 5 years
Steroidal Contraception
They contain synthetic female hormones (oestrogen & progesterone) which are steroid in
nature.
1) Oral
2) Injectable
3) Newer Sustained Release Systems
1) Oral Pills
a) Combined Oral Pills
- Combination of oestrogen & progesterone. 21 such tablets are supplied in a pack of
28 tablets, the last 7 tablets are placebo. Placebo contains iron & vitamins, to
complete the menstrual cycle.
- Commonly used oestrogen is ethinyl estradiol (EE) 30 μg.
- Commonly used progesterone is norethisterone 1 mg, DL norgestrel, levonorgestrel,
ethynodiol diacetate, lynestrenol etc.
- It is started from any of the first 5 days of the cycle. It is taken daily one; preferably
at bedtime for 21 days.
- Second pack is started after 7 days irrespective of onset or stoppage of
menstruation. It is supplied by the Govt.
b) Phasic Oral Pills

i) Biphasic -> All 21 tablets contain oestrogen and progesterone, but the dose
of progesterone is doubled after 1st 10 days; the dose of oestrogen remains constant.
Not popular in India due to slightly high failure rate.
ii) Triphasic -> All 21 tablets contain oestrogen and progesterone, but the dose
varies in 3 phases. It is started from the 5th day of cycle while 2nd pack is started after
7 days of pack free interval.
c) Minipill
- Contains only progesterone; i.e. Norgestrel 75 μg or Norethisterone 350 μg or
Levonorgestrel 30 μg
- Brand name: Cerazette - 75 μg desogestrel
- To be taken daily one throughout the cycle & at the same time each day. It inhibits
ovulation and acts locally by making the endometrium unreceptable for implantation
and renders the cervical mucous hostile to sperms.
- It is effective after 7 days.
Benefits of Minipill: It avoids undesirable side effects of oestrogen found with

combined pill; sickle cell patients or lactatingmothers can take it also.
Disadvantages of Minipill: Failure rate is more compared to combined OC pills.

Menstrual -> irregularities & amenorrhoea are common
Side effects -> alopecia, loss of libido, weight gain, nervous irritability
d) Newer pills
- Intimacy plus 2; Femilon- 20 μg ethinyl estradiol
- Post-coital pill (emergency contraception)
- Once a month pill; 3 mg Quinesterol (long acting oestrogen) & 12 mg
megesterol acetate (progesterone) -> not available in India
Mechanism of Action of Steroidal Contraception:

- Inhibition of ovulation
- Making the endometrium unsuitable for implantation.
- Progesterone makes the cervical mucous thick viscid, scanty & impermeable to sperms.
- Effect of tubal motility by progesterone
Contraindications:
Absolute: Thrombo-embolic disease, Acute or chronic disease of liver, Cancer of breast or
genitals, Pregnancy (known or suspected), Focal migraine
Relative: Hypertension, Vulvular heart disease, Epilepsy, Smokers over 35 years, Nursing
mothers, Sickle-cell anemia, Thalassemia, Asthma, Allergic disorders, Herpes gestationalies,
Varicose veins, Obesity, Elective surgery, Diabetes, Chron’s disease
Side Effects & Complications:

Nausea & vomiting, Break through bleeding, Absence of withdrawal bleeding (pills
amenorrhoea), Hypertension, Cardiovascular diseases, Weight gain, fluid retention, Breast
pain, tenderness, engorgement, Neoplasia, Return fertility may be delayed for 1 to 2 months
after stopping pills
Failure Rate = Less than 0.5%
Other Uses of Pills:

Regularization of cycles, DUB, Endometriosis, Postponement of menses, Primary
dysmenorrhoea, Suppression of functional ovarian cysts
Indications for Stopping Pills:

Pregnancy (pill failure), Uncontrollable side effects, Development of complications, If patient
wants to conceive, If patient forgets to take tablets for consecutive two days, Age > 35 years
in smokers otherwise at 50 years of age, Six weeks before elective surgery
2) Injectable Contraception
a) Long acting progestins; DMPA, NET-EN
b) Combined injectables (oestronge & progesterone)
DMPA
- Depot medroxyprogesterone acetate -> 150 mg every 3 months
- It is highly effective, long acting, safe, reversible & easy to administer.
- Given deep I.M. every 3 months in gluteus or deltoid muscle with all aseptic
precautions.
- Time: within 7 days of menstrual cycle immediately after abortion & MTP post
partum within 7 days.
- Failure rate = < 1/100 women years
- Mechanism of action -> same as OC pills
- Return of fertility -> 7 to 9 months after the last injection
Advantages of DMPA:
Very effective, Long term, Does not interfere with sex, Reduces incidence of PID &
vulvovaginitis, Can be used at any age, No oestrogen related side effects, Can be used
in nursing mothers, Helps in preventing uterine fibroids & endometrial cancer
Disadvantages of DMPA:
Delayed return fertility, Menstrual irregularity & amenorrhoea -> 10 to 15%,
Weight gain of 1-2 kg each year
Side effects -> headache, breast tenderness, mood swings, nausea, hair loss, less sex
drive
3) Newer Sustained Release Systems

a) Subdermal Polysiloxane Capsules (Norplant)
- It is a long acting, low-dose, progestin only contraceptive system for women.
- Highly effective and reversible.
- Norplant-2 rod system (Jadelle) – 2 silastic rods; total 140 mg levonorgestrel
- Rod implanted subdermally in women’s arm employing a minor surgical technique.
- Time: within 7 days after onset of menstruation, Immediately after abortion or first
trimester MTP.
- Implant becomes effective within 24 hours of placement.
- Mechanism of action: on cervical mucous & endometrium, inhibit ovulation by 50%
- Failure rate: < 0.5 per HWY
Contraindications: Anticoagulant therapy, Undiagnosed AUB, Known or suspected

Pregnancy, Liver disease
Removal: After 5 years, by a minor surgical technique

Side effects: Bleeding disorders, Amenorrhoea, Nausea, Loss of appetite, Dizziness,
Headache, Change in libido, Depression, Acne, Infection or pain at implant site
b) Biodegradable Implants
- They deliver progesterone form a carrier that gradually dissolves & disappears.
- They are easier to insert & need not be removed.
c) Silastic Vaginal Rings

- Women can insert & remove themselves.
- Immediately reversible.
- Progesterone is slowly released from the ring & can be absorbed through the
Vaginal epithelium.
- Ring can be removed up to 3 hours for comfort during intercourse or for cleaning.
- Failure rate: 1.2 to 1.5 / HWY
d) Contraceptive Patch
- EVRA -> combined oestrogen and progesterone patch.
- It is a square patch 4-4.5 cm long.
- It delivers to the blood stream 20 μg of ethinyl estradiol & 150 ug norelgestromin.
- Every week new patch is worn. After 3 weeks no patch is worn for 1 week.
- Applied over abdomen, buttocks, thighs, upper outer arms, upper back
- The patch is applied to a new location each week
- Side effects: skin irritation or rash at site
- Failure rate: < 1 / HWY
Emergency Contraception
It is an emergency procedure to prevent pregnancy following an unprotected but possibly
fertile intercourse.
Indications: Unprotected intercourse, Failure of barrier method, Unsuccessful coitus

interuptus, Missed OC pills, Sexual assault
Methods:
1) Yuzpe method
2) Progesterone-only pills
3) IUCD
4) Antiprogesterone
1) Yuzpe method
- Combined OC pills (ethinyl estradiol 50 μg + norgestrel 500 μg)
- 2 pills should be taken as early as possible (within 12-72 hours of intercourse)
- After 12 hours of first dose, another 2 pills are taken.
2) Progesterone-only pills
- Levonorgestrel 0.75 mg
- 2 doses 12 hours apart; 1st dose within 72 hours of intercourse
- Brand name: Ecee 2, Pill 72, Preventol Norlevo, etc.
3) IUCD
- Insertion of copper IUCD
- Within 5 days of intercourse (more time available compared to hormonal emergency
contraception)
4) Antiprogesterone
- Mefipristone (RU-486) - 600 mg oral single dose
- Within 72 hours of intercourse
Failure rate
- Different hormonal method = < 2%
- IUCD = 0.1%
 Family Planning
(Parivara Niyojana)
WHO defined family planning as: “A way of thinking & living that is adopted voluntarily,
upon the basis of knowledge, attitudes & responsible decisions by individuals & couples,
in order to promote the health & welfare of the family group & thus contribute
effectively to the social development of a country.”
Family planning is the voluntary planning and action, taken by individuals or couples to
prevent, delay or achieve a pregnancy.
Objectives: ▪ To avoid unwanted pregnancies.

▪ To bring about wanted pregnancies.
▪ To regulate the interval between pregnancies.
▪ To determine the number of children in the family.
▪ To control the time at which pregnancies occur in relation to the age
of the parents.
Birth Control & Contraceptives -> Refer to previous topic
 Reproductive and Child Health Care (RCH) Program

Onset: 15th October, 1997
National Family Welfare Program was renamed as Reproductive and Child Health Care.
Reproductive and Child Health approach is defined as:
“People have the ability to reproduce and regulate their fertility, women are able to go
through pregnancy and their birth safely, the outcome of pregnancy is successful in
terms of maternal and infant survival and wellbeing and couples are able to have sexual
relations free of fear of pregnancy or of contracting diseases.”
This program aims to reduce infant, child and maternal mortality. The objectives of the
program were to educate about planned pregnancies, promotion of health of pregnant
mothers, nutritional supplementation to pregnant and lactating women, counselling
about family planning methods and education about reproductive health in adolescents.
Highlights of the program:

- Prevention and provision of services for Sexual Transmitted Diseases (STDs) and
Reproductive Tract Infections (RTIs).
- Essential and emergency obstetric care. 24-hour delivery services at PHCs/CHCs.
- Essential newborn care
- Medical Termination of Pregnancy (MTP)
- Prevention and control of Vitamin A deficiency and Anemia in children
- Oral Rehydration Therapy (ORT) in case of diarrhoea
- Management of Acute Respiratory Infections (ARI)
- Universal Immunization Program (UIP)
 Maternal and Child Health (MCH) Program
Maternal and Child Health Program is one of the main components declared at the Alma
Atta Conference in 1978.
MCH Care services are free of charge and are available for women & children for
preventive & curative cases.
Aims of MCH Program: ▪ Re-education of maternal, perinatal, infant and childhood

mortality and morbidity.
▪ Promotion of reproductive health.
▪ Promotion of physical and psychological development of the
child and adolescent in the family.
Maternal Health: ▪ Provision of ante-natal care including regular examination,

immunization, proper nutrition and self-care.
▪ Provision of safe delivery site
▪ Post-natal follow up
▪ Family planning services
▪ Health education
Child Health: ▪ Growth and development monitoring including proper

nutrition with emphasis on breastfeeding.
▪ Early discovery of congenital abnormalities.
▪ Immunization
▪ Health education
 Ethical and Medico-Legal Issues in Prasuti Tantra & Stree Roga
POTENTIAL AREAS IN PRASUTI TANTRA
 Antepartum care
- History collection: History taking from the age of the patient with relevant
complaints, relevant past and family history with special reference to the obstetrical
history is important. Avoidance of any relevant factors can cause maternal and foetal
hazards.
- Investigations: Investigation without informed consent can lead to medico-legal
problems.
- High-risk pregnancies: These are only picked up through proper history taking,
examinations and investigations. Failure to detect a high-risk pregnancy, lack of care
and failure of timely referral can create medico-legal problems.
- Antenatal screening for congenital abnormalities should be done.
- Failure of timely detection of IUGR may cause intrauterine foetal death and the
doctor may be summoned to court.
 Medical Termination of Pregnancy Act

The act was legally enacted in 1971 and implemented in April 1972.
The basic principle is that pregnancy can be terminated when there are some
maternal or foetal indications. In India it is done before 20 weeks of gestation.
Legal problems occur in certain conditions as follows:
- Continuation of pregnancy after the procedure.
- Excessive or continued bleeding.
- Injury either to the uterus or to other organs.
- Death following any procedure.
- MTP done by an unauthorized person.
- MTP without proper counselling and informed consent.
- Termination knowingly after 20 weeks of pregnancy.
 Sex Selection and PNDT Act

- To identify genetic and congenital abnormalities in relation to sex. Unfortunately,
this test was misused. Prenatal sex determination and selective female foeticide
became widespread allover in India.
- Amendment of PNDT act in 2002, prohibits unnecessary sex determination without
any disease problem and aims at preventing selective abortions of female foetuses.
 Intrapartum Care
- Proper intrapartum management during labour is essential for a healthy mother
and a healthy child.
- Caesarean section: Increased incidence of caesarean section is associated with
increased maternal morbidity and mortality.
- Delayed decision of CS must be avoided as this may lead to undesirable situations
like obstructed labour causing maternal and foetal morbidity and mortality.
- Difficult vaginal delivery / instrumental delivery should be avoided.
 Postpartum Care
Drugs in pregnancy and lactation period should be selected and given with care.
 Ethical Issues in Surrogacy

- Surrogacy is a method of assisted reproduction where intended parents work with a
gestational surrogate who will carry and care for their baby(ies) until birth.
- According to fertilization act 1990, the carrying mother is the mother in law.
- Genetic mother can get legal parenthood by legal procedures only.
 HIV Positive Women in Pregnancy:

Neither the child nor women should suffer from any discrimination on HIV status.
POTENTIAL AREAS IN STREE ROGA
 Examination of Gynecological Patient

Professional and personal conduct: Prior to examination consent must be taken and
she must be informed about the nature of examination.
Examination should be done in a closed space in comfortable position maintaining
the privacy in presence of a female attendant.
 Diagnosis of Gynecological Disease

Proper history taking, investigations, diagnosis & referral.
 Forensic Gynecology
Sexual assault, domestic violence and rape must be handled in a sensitive manner.
 Female sterilization
- Inadequate consent
- Defective surgery
- Failed sterilization and the consequent wrongful pregnancy .
 Contraception
- IUCD
- Expulsion of device; confirmatory proof should be obtained.
- Complications of IUCD
- IUCD failure
 Infertility and ART

- Assisted conception is replete with ethical and legal problems.
- There is increasing litigation following the adverse outcome of multiple pregnancy.
- The couple should be informed and receive proper explanation about the different
methods of treatment along with the success rates and possible hazards.
 National AIDS Control Program (NACP)
First detected case of HIV: 1986
Onset of NACP: 1987
1992 - NACP I
1999 - NACP II
2002 - National AIDS Control Policy
2007 - NACP III launched for 5 years (2007 – 2012)
2012 - NACP IV launched for the next 5 years
 NACP I, 1992
National AIDS Control Organization (NACO) and National AIDS Control Board was set
up to implement the project.
Objective: To slow down the spread of HIV infection so as to reduce morbidity,
mortality and impact of AIDS in the country.
Strategies: Focus on raising awareness; measures to ensure safe blood access and
preventive services for high risk populations; improving surveillance for monitoring
HIV epidemic.
Achievements:
- Strong partnership with WHO
- Establishment of the state AIDS control cells
- Improved blood safety
- Improved condom promotion activities
- Development of national HIV testing policy
 NACP II, 1999

Objectives:
- Reduce the spread of HIV infection in India.
- To Increase India’s capacity to respond to HIV on a long term basis.
Strategies:
- Adoption of National AIDS Prevention and Control Policy
- Adoption of National Blood Policy
- Targeted interventions for high risk groups in high prevalence states
- Preventive interventions for general populations
- Involvements of NGOs
Achievements:
- Launch of National Adolescent Education Program
- Introduction of counselling, testing and PPTCT Program
- Launch of National Anti-Retroviral Treatment (ART) Program
- Launch of National Council on AIDS
- Nationwide behavioural sentinel surveillance were conducted.
- Computerized management information system was created.
- HIV prevention & care and support networks were strengthened.
 NACP III, 2007-2012
Aims: Halting and reversing the HIV epidemic in India over its five-year period by
scaling up prevention efforts among high risks groups and general population and
integrating them in care, support and prevention services.
Objectives: Reduce the rate of incidence by 60% in high prevalence states and by
40% in vulnerable states.
Strategies: Prevention by ICTC, blood safety and condom promotion
Achievement:
- The capacities of State AIDS Control Societies and District AIDS Prevention and
Control Units have been strengthened.
- Technical support units were established.
- 306 fully functional ART center & 612 LINK ART center, 259 Community centers
were established
- 12.5 lakh PLHIV were registered & 4.2 lakh patients were on ART.
- 3.000 Red ribbon clubs were established
- Link workers training module updated & condom promotion program was
strengthened.
 NACP IV, 2012-2017

Aim: To halt and reverse the epidemic in India over the next 5 years by integrating
programs for prevention, care, support & treatment.
Objectives:
- Reduce new infections by 50%.
- Provide care, support & treatment to all people living with HIV/AIDS.
Component-1: Intensifying and consolidating prevention services with a focus on
HRG and vulnerable populations.
Component-2: Expanding IEC services for general population and high risk groups
with a focus on behaviour change and demand generation.
Component-3: Comprehensive care, support & treatment.
Component-4: Strengthening institutional capacities.
Component-5: Strategic information management systems.
 PPTCT Program, 2002

Prevention of Parent-to-Child Transmission of HIV/AIDS.
- The aim of the PPTCT program is to offer HIV testing to every pregnant woman in
the country, so as to cover all estimated HIV positive pregnant women and eliminate
transmission of HIV from mother-to-child.
- The PPTCT services provide access to all pregnant women for HIV diagnostic,
prevention, care and treatment services.
 CST – Care Support and Treatment

The care, support and treatment component of NACP aims to provide comprehensive
services to people living with HIV with respect to free Anti-Retroviral Therapy (ART);
Psychosocial support; Prevention and treatment of opportunistic infections including
tuberculosis; Facilitating home-based care.
 Prenatal Diagnostic Technique (PNDT) Act, 1994
OR Preconception Prenatal Diagnostic Technique (PCPNDT) Act
PNDT Act provides rules and regulations for use of diagnostic procedures / test /
techniques carried out prenatally to detect genetic, chromosomal, metabolic disorders,
etc. The main purpose of the act is to regulate the misuse of such techniques and
prevent prenatal sex determination.
The act specifies about:

- Criteria for conducting prenatal diagnostic techniques.
- Terms and conditions for using prenatal diagnostic tests.
- Regulations for genetic centers, clinics, laboratories, etc.
- Regulations for infertologists, sonologists, geneticists, and whoever is involved in
prenatal diagnostic tests or procedures.
Prenatal diagnostic tests include USG, analysis of amniotic fluid, chorionic villi, blood or
any tissue or fluid of a pregnant woman or conceptus conducted to detect the above
mentioned anomalies.
The purpose of the act is to provide prohibition of sex selection procedures i.e. any
procedure, technique or test prescribed or administered for the purpose of ensuring or
increasing the probability of an embryo to be of particular sex before or after conception
thereby preventing misuse for sex determination leading to female foeticide.
Terms and condition for using prenatal diagnostic tests:

i) Age of pregnant woman >35 years
ii) A pregnant woman who has undergone two or more spontaneous abortions,
miscarriages or foetal losses.
iii) A woman who has been exposed to teratogenic agents during pregnancy.
iv) A woman with positive family history of mental retardation or spastic or genetic
disorder.
v) Any other condition specified by the Supervisory board.
Penalties for doctors or owners of clinics under PNDT Act, 1994:

- Up to 3 years of imprisonment with fine up to Rs. 10,000 for first offence.
- Up to 5 years of imprisonment with fine up to Rs. 50,000 for subsequent offence.
- Suspension of medical registration of the doctor if the charged are framed.
- Cancellation of medical registration of the doctor for 5 years by the state medical
council in case of first offence and permanent cancellation in case of subsequent
offence.
-> The pregnant woman is considered innocent under the Act, unless and until proved
otherwise.
 Medical Termination of Pregnancy (MTP) Act, 1971
Medical Termination of Pregnancy Act is an act to provide for the termination of certain
pregnancies by registered medical practitioners and for matters connected therewith or
incidental thereto.
Termination of pregnancy under this law is permitted up to 20 weeks of gestation and
not beyond that. Written consent on prescribed form from the patient is mandatory; in
case of patient being a minor (<18 years) or lunatic or mentally retarded, written consent
of the legal guardian must be obtained.
The act specifies about:

1) Requirements for MTP
2) Person qualified to perform MTP
3) Place for performing MTP
1) Requirements for MTP:
▪ A pregnancy may be terminated by a registered medical practitioner:
(a) where the length of the pregnancy does not exceed twelve weeks if such medical
practitioner is…
(b) where the length of the pregnancy exceeds twelve weeks but does not exceed twenty
weeks, if not less than two registered medical practitioners are…
… Of opinion, formed in good faith, that:
(i) the continuance of the pregnancy would involve a risk to the life of the pregnant
woman or of grave injury physical or mental health.
(ii) there is a substantial risk that if the child were born, it would suffer from such
physical or mental abnormalities as to be seriously handicapped.
▪ In determining whether the continuance of pregnancy would involve such risk of injury
to the health as is mentioned in sub-section (ii), account may be taken of the pregnant
woman's actual or reasonable foreseeable environment.
▪ No pregnancy of a woman, who has not attained the age of eighteen years, or, who,
having attained the age of eighteen years, is a lunatic, shall be terminated except with
the consent in writing of her guardian. (b) No pregnancy shall be terminated except with
the consent of the pregnant woman.
2) Person qualified to perform MTP:

▪ Registered medical practitioner having postgraduate training or qualification in
obstetrics and gynecology or trained at a recognized MTP center.
▪ MTP ≤ 12 weeks of gestation warrants an additional opinion of another registered
medical practitioner.
3) Place for performing MTP:

No termination of pregnancy shall be made in accordance with this Act at any place
other than:
(a) a hospital established or maintained by Government.
(b) a place for the time being approved for the purpose of this Act by Government.
 Surrogacy (Regulation) Bill, 2020
Surrogacy is an arrangement where a woman (the surrogate) offers to carry a baby
through pregnancy on behalf of a couple, and then return the baby to the intended
parent(s) once it is born.
Surrogacy has been a long debated topic in India. The ethicality of “borrowing” a womb,
and the moral and legal complexities surrounding it, have always been matters of
concern. The surrogacy regulation bill tries to regulate the practice of Surrogacy by
banning practices like womb hiring. It tries to establish a delicate balance between
Rights of Infertile couple and the Human rights of Surrogate mothers.
 It allows any willing woman to be a surrogate mother. (2019 bill had proposed that
only a close relative of a couple can be a surrogate mother).
 Deleting the definition of “infertility” as the inability to conceive after five years of
unprotected intercourse on the ground that it was too long a period for a couple to
wait for a child.
 It proposes to regulate surrogacy by establishing a National Surrogacy Board at the
central level and State Surrogacy Board and appropriate authorities in states and
Union Territories respectively.
 The proposed insurance cover for surrogate mothers has now been increased to 36
months from 16 months provided in the earlier version.
 Commercial surrogacy will be prohibited including sale and purchase of human
embryo and gametes.
 Only ethical surrogacy to Indian married couples, Indian-origin married couples and
Indian single woman (only widow or divorcee between the age of 35 and 45 years)
will be allowed on fulfilment of certain conditions.
The practice of surrogacy has persisted in India without any legal framework, working
only on the basis of vague guidelines. Now with the changes in the bill, a regulatory
framework will be adopted to monitor surrogacy.
In recent times, unethical practices including the exploitation of surrogate mothers,

abandonment of children born out of surrogacy and the import of human embryos and
gametes have been reported. Many poor women in India took to becoming surrogate
mothers repeatedly despite grave implications to their health.
With the banning of commercial surrogacy and with the provision of insurance for 36
months, the exploitation of surrogate mothers will be checked as well as there will be
improvements in their health.
 Record Keeping
- Medical record is a legal document providing a chronicle of the patient's medical
history and care.
- The medical record includes a variety of types of "notes" entered over time by health
care professionals to record observations, administration of drugs and therapies, orders
for the administration of drugs and therapies, test results, x-rays, reports, etc.
 Use of Medical Records:

- To document the course of the patient’s illness, treatment and improvement.
- Communication between attending doctors and other healthcare professionals.
- Collection of health statistics
- Legal assurance and might be important for court cases
- Insurances cases
 Retention of Medical Records:

- OPD records -> 5 years (Outpatient department)
- IPD records -> 10 years (Inpatient department)
- MLC records -> 30 years or more (Medico-legal case)
 Types of Medical Records:

1) Inpatient Department Record
2) Outpatient Department Record
3) Operation Theatre Record
1) Inpatient Department Record

The patient’s name and medical record number should be written on the
medical record folder.
Components:
- Information & identification sheet, Admission note
- Clinical progress note, Nurses progress note
- Diagnostic reports
- Blood Transfusion notes
- Informed Consent should be taken for all treatment procedures, surgical
procedures and diagnostic procedures.
- Operation note and anesthesia note should be made for all surgical procedures
like D&C, Polypectomy, caesarean section, etc.
- Investigation reports like X-ray, etc.
- Orders for treatment and medication forms listing daily medications ordered
and given with signatures of the doctor prescribing the treatment and the nurse
administering it.
- Discharge summary, referral slip
- Seperate record keeping for diagnostic procedures and treatment procedures
like USG, HSG and IUI.
- Seperate record keeping for treatment procedures like Uttarabasti, Basti,
Yoniprakshalana, Yonipurana. Yonidhupana, etc.
Completion of Medical Records:
- The consent form for treatment has been signed by the patient.
- Patient identification details (name and medical record number) are correct
and entered on all forms.
- Doctors have recorded all essential information.
- Doctors have signed and dated all clinical entries.
- The front sheet has been completed and signed by the attending doctor.
- Nurses have recorded and signed all daily notes regarding the condition and
care of the patient.
- All the orders for treatment have been recorded in the medication form and
signed.
- Medication administration has been recorded and signed.
- The anesthetic form (if any) has been completed and signed.
- The operation form (if any) has been completed and signed.
- The main condition/principle diagnosis has been recorded on the front sheet.
- Operations and/or procedures have been recorded on the front sheet.
- Diagnostic reports have been attached.
- Discharge/referral summary is duly filled and signed.
2) Outpatient Department Record

Out patient record register:
OPD Number, Patient name, Age, Sex, Diagnosis
OPD Case Sheet:

- Antenatal, postnatal and gynecological cases should be filled properly.
- Detailed history should be taken.
- Informed consent for examination should be taken.
- Clinical examination should be recorded.
- Investigation should be recorded.
- Diagnosis should be recorded.
- Treatment advised should be recorded.
3) Operation Theatre Record

- Individual records should be maintained for anesthesia, CS, D&C, D&E,
Polypectomy and Sterilization.
- Proper recording should be made with preoperative, operative and post-
operative notes
 Ayurvedic Drugs used in Prasuti Tantra & Stree Roga
Rajah Pravartini Vati

 Reference: Bhaishajya Ratnavali
 Ingredients: Shuddha Tankana, Hingu, Kasisa, Kumari (Kanya) sara, Kumari svarasa
 Indications: Artavakshaya, Anartava, Kashtartava, Vandhyatva
 Contraindication: During pregnancy, Asrigdara
 Matra: 125-250 mg, 1-2 tablets once or twice a day (for 3 months)
 Anupana: Udaka
Kanyalohadi Vati
 Reference: Rasoddhar Tantra
 Ingredients: Kanya, Kasis Bhasma, Loha Bhasma, Tvak, Ela, Shunthi, Kumari svarasa
 Indications: Artavakshaya, Anartava, Kashtartava, Vandhyatva; gynecological
disorders caused due to low hemoglobin level or anemia.
 Contraindication: During pregnancy

 Matra: 125-250 mg, 1-2 tablets once or twice a day (for 3 months)
 Anupana: Ushnodaka
Chandraprabha Vati
 Reference: Bhaishajya Ratnavali
 Ingredients: Chandraprabha (Karpura), Vacha, Musta, Bhunimba, Amrita, Devadaru,
Haridra, Ativisha, Dari, Pippalimula, Chitraka, Dhanyaka, Triphala (Haritaki, Bibhitaki,
Amalaki), Chavya, Vidanga, Gajapippali, Vyosha (Shunti, Maricha, Pippali), Makshika
Bhasma, Kshara dvaya (Svarjika and Yava Kshara), Lavana traya (Saindhava, Vida,
Sauvarchala Lavana), Trivrit, Danti Patra, Tvak, Ela, Vamshalochana, Loha Bhasma,
Sharkara, Shilajatu, Guggulu
 Indications: Mutrakricchra, Ashmari, Vibandha, Granthi, Arbuda, Pandu, Katishula,

Kandu, Shwetapradara, Kashtartava, Shukra Dosha
 Matra: 250-500 mg, 2 tablets twice a day (for 3 months)

Prataplankeshvara Rasa
 Reference: Rasoddhar Tantra, Sutika Roga Chikitsaprakarana
 Ingredients: Rasasindoor, Tamra Bhasma, Svarnamakshika Bhasma, Shuddha Shilajit,
Parada, Gandhaka, Shankha Bhasma, Shukti Bhasma, Abhraka Bhasma, Loha Bhasma,
Shunthi, Maricha, Pippali, Pippalimula, Vanotpala (Gomaya) Bhasma, Devadarvyadi
Kwatha
 Indications: Sutika Jvara, Sutika Roga

 Matra: 125 mg, once or twice a day
Garbhapala Rasa
 Reference: Rasa Tantra Sara, Siddha Yoga Sangraha
 Ingredients: Shuddha Hingula, Naga Bhasma, Vanga Bhasma, Twak, Ela, Patra,
Shunthi, Maricha, Pippali, Dhanyaka, Krishna Jeeraka, Chavya, Draksha, Devadaru,
Loha Bhasma, Aparajita Swarasa
 Indications: Garbha-avastha, Garbhashosha

 Matra: 125 mg, once or twice a day
 Anupana: Ushnodaka / Draksha Kvatha
Shonitargal Rasa
 Reference: Anubhuta
 Ingredients: Rasasindoor, Svarnagairika, Loha Bhasma, Abhraka Bhasma, Yashada
Bhasma, Shuddha Sphatika, Rasanjana, Raktachandana, Ashwattha Niryasa
 Indications: Asrigdara, Yonisrava

 Matra: 250 mg, twice a day
Pushyanuga Churna
 Reference: Charaka Samhita, Astanga Sangraha, Astanga Hridaya
 Ingredients: Patha, Jambu, Amra, Shilajit, Rasananjana, Ambastha, Shalmali piccha
(Mocharasa), Lajjalu, Vatsaka tvak, Vahlika, Ativisha, Bilva, Musta, Lodhra, Gairika,
Katvanga, Maricha, Shunthi, Mridvika, Raktachandana, Katphala, Vatsaka phala,
Ananta, Dhataki puspa, Madhuka, Arjuna tvak
 Indications: Yoni Dosha, Rajo Dosha, Shvetapradara, Atisara, Grahani, Raktapitta

 Matra: 1-3 gm, once or twice a day (for 3 months)
 Anupana: Kshaudra & Tandulodaka
Dashamula Kvatha
 Reference: Bhaishajya Ratnavali, Sutika Roga Chikitsaprakarana
 Ingredients: Bilva, Agnimantha, Shyonaka, Patala, Gambhari, Brihati, Kantakari,
Shalaparni, Prishnaparni, Gokshura, Udaka
 Indications: Artavakshaya, Anartava, Kashtarava, Sutika Avastha, Sutika Roga,

Katishula, Paripluta Yonivyapad, Vandhyatva
 Contraindications: During pregnancy

 Matra: 15-30 ml, twice a day (on empty stomach for 3 months)
Devadarvyadi Kvatha
 Reference: Bhaishajya Ratnavali, Sutika Roga Chikitsaprakarana
 Ingredients: Devadaru, Vacha, Kustha, Pippali, Shunti, Bhunimba, Katphala, Musta,
Kiratatikta, Dhanyaka, Haritaki, Gajapippali, Kantaki, Gokshura, Dhanvayasa, Brihati,
Ativisha, Guduchi, Karkatashringi, Krishna Jeeraka, Udaka
 Indications: Kashtartava, Sutika Awastha, Sutika Roga, Sutika Makkala, Katishoola

 Matra: 15-30 ml, twice a day (on empty stomach for 3 months)
Panchavalkala Kvatha
 Reference: Bhavaprakasha Nighantu, Mukharoga
 Ingredients: Vata, Udumbara, Ashwattha, Plaksha, Parisha, Udaka
 Indications: Internal -> Shvetapradara, Asrigdara
External -> Yoniprakshalana in Shvetapradara, Yonishotha,
Garbhashaya Greevavrana, Garbhashaya Greevashotha
 Matra: Internal -> 15-30 ml, twice a day (on empty stomach for 3 months)
External -> 500 ml (Yoniprakshalan) / Q.S.
Phala Ghrita
 Reference: Sharangadhara Samhita
 Ingredients: Yastimadhu, Haritaki, Bibhitaki, Amalaki, Kustha, Haridra, Daruharidra,
Katurohini, Pippali, Vidanga, Musta, Indravaruni, Katphala, Ashvagandha, Shatavari,
Vacha, Sariva, Priyangu, Shatapuspa, Hingu, Chandana, Raktchandana, Rasna,
Jatipuspa, Kamala, Vamshalochana, Ajamoda, Dantimula, Ghrita, Ksheera
 Indications: Vandhyatva, Artavadusti, Vamini Yonivyapad, Putraghni Yonivyapad,

Garbha-avastha, Garbhashosha
 Matra: 15-20 gm, twice a day (on empty stomach for 3 months)
 Anupana: Ushnodaka, Ksheera
Jatyadi Taila
 Ingredients: Jati, Nimba, Patola, Naktamala, Sikta, Madhuka, Kustha, Haridra,
Daruharidra, Manjista, Katurohini, Padmaka, Lodhra, Abhaya, Nilotpala, Tuttha,
Sariva, Naktamala Beeja, Tila Taila
 Indications: External for Yonipichu -> Shvetapradara, Yonishotha, Yonikandu,

Garbhashaya Greevavrana, Garbhashaya Grivashotha
 Matra: 5 ml (Yonipichu)
Bala Taila
 Reference: Sushruta Samhita, Chikitsa Sthana (15)
 Ingredients: Bala, Chhinnaruha, Rasna, Mastu, Ikshurasa, Shukta, Taila, Ajaksheera,
Shati, Sarala, Daru, Ela, Manjista, Agaru, Chandana, Padmaka, Atibala, Musta,
Mudgaparni, Mashaparni, Harenu, Yashti, Surasa, Vyaghranakha, Rishabhaka, Jivaka,
Palasha, Kasturi, Neelika, Jati, Sprikka, Kumkuma, Shaileya, Jatiphala, Katphala,
Ambu, Twak, Kunduru, Karpura, Turushka, Shrinivasaka, Lavanga, Nakha, Kankola,
Kustha, Mamsi, Priyangu, Sthauneya, Tagara, Dhyama, Vacha, Madanaka,
Nagakeshara
 Indications: Basti prayoga during Basti Kala (9th month of pregnancy), Abhyanga
prayoga during Stuika Kala, Matra Basti for Putraghni Yonivyapad, Vamini
Yonivyapad, Vandhyatva
 Matra: 60-120 ml (Basti)

Kumaryasava
 Ingredients: Kumari Svarasa, Guda, Makshika (Madhu), Pakva Loha Bhasma, Shunthi,
Maricha, Pippali, Lavanga, Tvak, Ela, Patra, Nagakeshara, Chitraka, Pippalimula,
Vidanga, Gajapippali, Chavya, Hapusha, Dhanyaka, Puga, Katurohini, Musta, Haritaki,
Bibhitaka, Amalaki, Rasna, Devadaru, Haridra, Daruharidra, Murva, Yastimadhu,
Danti, Pushkaramula, Bala, Atibala, Kapikacchu, Gokshura, Shatapuspa, Hingupatri,
Akallaka, Utingana, Shveta Punarnva, Rakta Punarnava, Lodhra, Makshika Bhasma,
Dhataki
 Indications: Artavakshaya, Anartava, Kashtarava; gynecological disorders due to low

hemoglobin level or anemia.
 Matra: 15-20 ml, twice a day after food (for 3 months)

 Anupana: Udaka (equal quantity)
Ashokarishta
 Reference: Bhaishajya Ratnavali, Pradara Adhikara
 Ingredients: Ashoka, Guda, Dhataki, Ajaji, Musta, Shunthi, Darvi, Utpala, Haritaki,
Bibhitaka, Amalaki, Amrasthi, Jeeraka, Vasa, Chandana
 Indications: Raktapradara, Shvetapradara

Dashamularishta
 Reference: Sharangadhara Samhita, Grahani Adhikara
 Ingredients: Bilva, Agnimantha, Shyonaka, Patala, Gambhari, Brihati, Kantakari,
Shalaparni, Prishnaparni, Gokshura, Chitraka, Pushkara, Lodhra, Guduchi, Amalaki,
Dhamasa, Khadira, Vijaysara, Haritaki, Kustha, Manjistha, Devadaru, Vidanga,
Yastimadhu, Bharangi, Kapittha, Bibhitaki, Punarnava, Chavya, Jatamamsi, Priyangu,
Sariva, Shahi Jeera, Tivrit, Harenuka, Rasna, Pippali, Puga, Shatti, Haridra, Shatpuspa,
Padmakha, Nagakeshara, Musta, Indrayava, Shunthi, Rushbhaka, Jivaka, Meda,
Mahameda, Kakoli, Kshirkakoli, Ridhhi, Vridhhi, Jala, Munakka, Madhu, Guda,
Dhataki, Kankola, Usheera, Shveta Chandana, Lavanga, Jatiphala, Tvak, Ela, Patra,
Nagakeshara, Pippali, Kasturi
 Indications: Pandu, Mandagni, Sutika Avastha, Artavkshaya, Arajaska Yonivyapad

 Pharmacotherapeutics of Allopathic Drugs in Obstetrics & Gynecology
Oxytocin
Naturally, oxytocin is secreted by the hypothalamus – supra-optic & paraventricular
nuclei.
Oxytocin as medicine:
 Half-life: 3-4 min (time required for the action to set in)
 Duration of action: < 20 min
 Indications:
1st trimester -> Abortion, Expulsion of H. mole
2nd trimester -> Termination of pregnancy
3rd trimester -> Induction and augmentation of labour
Post-partum -> Prevention of PPH
 Dose & Route of Administration:

1) I.V.
- RL, D5, DNS -> 500 ml
- 5 units of oxytocin
- 6-8 drops / min
2) I.M.
- 10 units
- Prevention of PPH; it is injected immediately after delivery.
 S/E: (Side Effects)

1) Maternal -> Uterine hyper-stimulation, Uterine rupture, Water intoxication,
Hypertension, Anti-diuresis
2) Foetal -> Foetal distress, Meconium stained liquor, Low APGAR score
 Diagnostic uses: Contraction stress test, Oxytocin sensitivity test
 Oxytocic Drugs: Hemabate, Methergine, Pitocin, Korlym, Prostin E2, etc.

Methergine
Methergine is an ergot derivative.
 M/A: (Mechanism of Action)

- Directly acts on the myometrium
- Contraction of uterus
- Contraction of cervix
 Route of Administration: I.M., I.V., Oral
 Indications:
- Prevention of PPH
- Treatment (Tx) of atonic PPH -> 3-4 doses, 4-6 hrs apart
- 1st trimester -> Prevention of PPH, Abortion & evacuation of H. mole
 S/E:
- Hypertension
- Nausea & vomiting
- Abdominal pain
- May interfere with lactation
 C/I: (Contraindications)
- Pre-eclampsia, Eclampsia
- Chronic HTN
- Cardiac diseases
- Rh-negative mother
Prostaglandins
- Prostaglandins are Paracrine / Autocrine hormones.
Paracrine action -> the hormone acts locally by diffusing from its source to target cells in
the neighborhood.
Autocrine action -> the hormone acts on the same cell that produced it.
- E & F series act on the uterus.
 PGE1
- Tablet
- Misoprostol -> M/A: Contraction of uterus, Cervical softening / ripening
- RoA: Oral, Vagina, Sub-lingual
- Dose: a) 25 μg -> Induction and augmentation of labour
b) 200 μg -> Cervical ripening, Hysteroscopy, Prevention of PPH,
Termination of pregnancy in 1st trimester
c) 600 μg -> Expulsion of retained products of conception,
Termination of H. mole
 PGE2
- Gel
- Dinoprostone gel (Cerviprime gel, Primigyn gel)
- M/A: Softening of cervix, Dilation of cervix, Contraction of uterus
- Uses: Induction and augmentation of labour, Termination of pregnancy
- RoA: Intracervical, Intravaginal (local application)
- Dose: 0.5 mg; Repeat after 6-8 hrs, 2-3 x
- Storage: 2-8°C (to maintain the cold chain)
 PGF2x
- Carboprost (Protodin / Carboprost)
- RoA: I.M.
- Dose: a) 125 μg -> Prevention of PPH
b) 250 μg -> Treatment of PPH; Repeat after 4-6 hrs, 3-4 x
-> Abortion
- Storage: 2-8°C (to maintain the cold chain)
- S/E: Common for PGE1, PGE2 and PGF2x -> Vomiting, Diarrhoea, Fever, Hyperthermia
Frucemide
Frucemide is very potent diuretic.
 RoA: Oral / IM / IV
 Dose: Inj. Lasix - 2 amp – 10-20 mg/ml
 Uses: Along with blood or packed cells transfusion in cases of severe anemia.
Pulmonary oedema i.e. in eclamptic patient. Cardiac failure in cardiac disease or
severe anemia. Massive oedema not relieved by conservative measures. Impending
acute renal failure in obs.
 Adverse Effects: Because of potassium depletion (hypokalemia) it causes weakness,

fatigue, dizziness & cramps. Orthostatic hypotention. Sudden deaths have been
reported after its paranteral use. With large doses-temporary or permanent
deafness. Decrease in placental perfusion. Thrombocytopenia & hyponatremiain
fetus. Foetal electrolyte imbalance.
Isosuprox / Turbutalin
Isosuprox is a tocolytic agent.
 M/A: Relaxation of uterine myometrium

 Name: Duvadilan, Vasodilan, Tidilan, Suprox
 Use: In premature labour to arrest uterine contractions.
 Dose:
- 40 mg in 500 cc of 5% glucose or glucose saline (DNS)
- I.V. drip started – 16 drops/min
- Increasing slowly upto 64 drops/min
- I.V. drip is continued for at least 4 hours after the concentration cease.
- Then 10 mg I.M. - 6 hrly for 24-48 hrs
- Then orally 10 mg - 6-8 hrly upto 37 completed weeks
 Contraindications: Tachycardia of more than 130 beats per min. Positive fluid
balance. Chronic cardiac disease. Chorioamnionitis. Dead or severely malformed
foetus. Along with MAO inhibitors. Concomittent use of steroids.
 Adverse Effects: Maternal tachycardia, hypotension, palpitation are common. There

may be transient dizziness, weakness, nausea, sweating, headache. Acute pulmonary
edema. Hypergysemia, hypokalemia.
In neonate: transient hypogysemia, hypokalamia, hypotension
Tranexamic Acid
Tranexamic acid is an antifibrinolytic agent.
 Action: Stabilization of clot

 Dose: 500 mg tab & 500 mg/amp injection
 Uses:
- Menorrhagia - 1 to 1.5 gms - 3 to 4 times /day
- Overdose of fibrinolytics agents
- Postoperatively - 10 to 25 mg/kg body wt-3 to 4 times per day by slow I.V. or orally
 S/E: Nausea, diarrhoea, headache, giddiness, hypotension
Anti-D
Anti-D is prepared from serum of immunized male volunteers or naturally immunized
women with high titre of anti-D antibodies.
 Brand Name: Rhogam, Rhiggal, Partobulin & monoclonal, Rhoclone
 M/A: It is neutralizing the foetal Rh positive cells which enter the maternal
circulation.
 Indications:
It is given to Rh negative mothers in following cases to prevent sensitization.
- Delivery of Rh positive foetus.
- Abortion of > 7 weeks pregnancy
- Amniocentesis
- External cephalic version
- Caesarean section
- Ectopic pregnancy
- APH
- Manual removal of placenta
 Contraindications: Rh positive women. Already sensitized Rh negative women. When

infant is Rh negative. To the neonate.
 RoA: Deep I.M.

 Dose: 300 µg 20-25 µg of drug protects against 1 ml of foetal blood.
 Timing: Preferably within 72 hours of the delivery. But if 72 hours have passed, it
should also be given as it may still be protective. To overcome failures prophylactic
antenatal administration of 300 µg anti-D at 28 weeks is suggested.
 S/E: Local reaction at the site of injection, fever

T.T. - Tetanus Toxoid
T.T. is prepared from tetanus toxin produced by clostridium tetani.
 M/A: Given to the mother during pregnancy, it produces active immunity in mother
& passive immunity by placental transfer of antibodies in the foetus. Thus it prevents
both maternal and neonatal tetanus.
 Schedule during pregnancy:

- In non-immunized pregnant mother:
Dose: 0.5 ml I.M.
First dose: 1st visit (as early as possible)
Second dose: 4-6 weeks after first dose
- If immunized in the past:

Only one booster dose is required in 3rd trimester, preferably 4 weeks before EDD.
 Adverse Reaction: Uncommon, incidence is 1-2%.

- Local: Excessive pain, redness & swelling around site of injection persisting for 3-4
days.
- General: Urticaria with or without angioneurotic oedema, frank serum sickness &
peripheral neuropathy have been rarely reported.
Cabergolin
- Cabergolin is a long acting dopamine receptor agonist with a high affinity for D2
receptors.
- It exerts a direct inhibitory effect on the secretion of prolactin by pituitary lactitrophs.
 Brand Name: Caberlin, Cabgolin 0.5 mg tablets

 Uses: Hyperprolactinemia, Inhibition of lactation
 C/I: Uncontrolled hypertension, Patient with history of puerperal psychosis.
 Dose:
- Hyperprolactinemia -> 0.5 mg orally weekly & increasing by 0.5 mg every month till
response is achieved (usually by 2 mg/wk)
- Inhibition of lactation -> 1 mg single dose in the first post-partum day, for
suppression of established lactation -> 0.25 mg 12 hrly for 4 doses.
 S/E: Nausea, Vomiting, Constipation, Abdominal pain, Headache, Dyspepsia,

Dizziness
Drotraverine
- Dotraverin is an isoquinoline antispasmodic.
- It relieves smooth muscle spasm by correcting cyclic AMP & calcium imbalance at the
spastic site.
 Dose & Route:

- 40 mg I.M. injection
- After 3 cm dilatation of cx
- Can be repeated after 3 hours if necessary
Clomiphene-Citrate
- Potent anti-oestrogenic & weekly oestrogenic action
- It is rapidly absorbed orally, cleared by liver & excreted in faeces.
 M/A: It interferes with hypothalamic or pituitary cytosol oestrogen receptor binding,

blocking oestrogen feedback and leading to increased FSH & LH; acts on ovary and
brings follicular growth & ovulation. Direct effect on ovarian steroidogenesis.
 Uses:
- Anovulatory infertility
- Ovulation induction in cases of PCOD
- In male patient with oligozoospermia
 Method of Administration:
- It is started from 2nd or 3rd day of period. Given in 50 mg daily dose for 5 days.
- Response is checked by detecting ovulation by serial USG examination.
- If ovulation does not occur the dose may be increased to 100 mg for 5 days in the
subsequent cycle. Dosage may be increased to 150 mg/day maximum.
- If ovulation is occurring but there is no pregnancy for 6 months, therapy should be
discontinued.
- To improve the ovulation rate clomiphene may be combined with inj. HCG (5000 IU
I/M ehrn the follicle is 18-20 mm on USG)
- In male patients 25.0 mg is given daily for 24 days with 6 days rest in every month
for 3-6 months to stimulate spermatogenesis.
 Contraindications: Liver diseases, AUB of unknown origin, Pregnancy, Neoplastic

disease of genital tract, Ovarian cyst other than PCOD
 Success Rate: Ovulation 70-80%; Pregnancy rate 40-50%
 Adverse reactions: Hyperstimulation, Multiple pregnancy, Increased incidence of

abortion, Hot flushes, Abdominal discomfort, Blurred vision, Luteal phase defect
Progesterone
- Progesterone is a natural steroid with 21 carbon atoms.
- It is mainly produced by corpus luteum from the ovary & during pregnancy from the
placenta. Adrenal glands contribute in very little amount.
- It is metabolized in the liver.
- Natural micronized & synthetic progesterone are useful orally for clinical use.
 Classification:
1) Natural progesterone (micronized P)
2) Derivatives of progesterone
3) Derivatives of testosterone
4) Derivatives of 19-nortestosteron
 Micronized Progesterone:
- RoA: Orally, vaginally, I.M. – Vaginal route is preferred unless there is bleeding. Due
to direct vaginal absorption & hepatic bypass it gives better blood levels and results.
- Dose: 100, 200 & 400 mg soft capsule or 50 & 100 mg I/M inj.
- Names: Susten, Nuturogest, vageston
- Uses:
a) Threatened abortion & Habitual abortion; 200 to 400 mg/day from confirmation of
pregnancy till 12th week of pregnancy. As compared to synthetic progesterone
natural micronized progesterone has better bio-availability and minimal side effects.
b) Infertility due to luteal phase defect; 200 to 300 mg/day from 16th day of cycle for
10 days.
Epidosin
Epidosin acts as an anticholinergic; it decreases involuntary muscle movement and helps
to treat pain associated with smooth muscle spasm.
Epidosin (Valethamate) injection -> 8 mg, I.M.
 Dose & Route:

- 1 ml injection containing 8 mg of valethamate bromide/ml
- Deep I.M. or I.V. injection
- It can be repeated after 20-30 min if required. Maximum 3 injection can be given.
 Uses: Gastrointestinal tract spasm, Ureteric and biliary colic, Cervical dilatation in
first stage of labour, Dysmenorrhoea, Reduction of post-operative pain
 C/I: Cardiac insufficiency, Severe HTN, Thyrotoxicosis, Glaucoma
 S/E: Blurred vision, Dilatation of pupils, Dysphagia, Constipation, Diarrhoea, Rash,

Chest pain, Headache, Tachycardia, Dry mouth, Urinary retention
Xylocaine
- Synonyms: Lidocaine, Lignocaine
- It is the most common used local anesthetic agent.
- It is available as 1% or 2% solution in 30 ml bulbs.
- It is stable, can be stored at room temp for a long time and can be autoclaved
repeatedly.
 Dose:
- For infiltration 0.5% concentration is used while for nerve block 1% concentration is
used.
- Effect starts within few minutes & lasts for 30 to 60 mins.
- Addition of vasoconstrictor like adrenaline prolongs the action upto 2 hours.
- Max safe dose -> 200 mg i.e. 20 ml of 1% solution.
 Uses:
As a local anesthetic in following condition:
- Infiltration anesthesia in laparoscopic TL, abdominal TL, episiotomy, before spinal
anesthesia. Resuturing of abdominal or perineal wound & LSCS in very serious
condition where GA is contraindicated.
- Paracervical block: for D & C, MTP, D & E, hysterectomy
- Pudendal block: for low mid forceps, vacuum extraction & assisted breech delivery
 S/E: Hypersensitivity reactions, CNS toxicity
Tocolytic Drugs
Drugs that prevent preterm labour and immature birth by suppressing uterine
contractions (tocolysis). Agents used to delay premature uterine activity include
magnesium sulfate, beta-mimetics, oxytocin antagonists, calcium channel inhibitors, and
adrenergic beta-receptor agonists.
PS & PV
 PS = Perspeculum Examination
- Generally performed except on pregnant or unmarried women.
- Required instruments: i) Sim’s speculum
ii) Anterior vaginal wall retractor
- Darshana pariksha
- Observe first & second Avarta in regard to abnormalities of appearance, discharge, etc.:
i) Prathama Avarta: External genital area, vagina

ii) Dvitiya Avarta: Cervix, external OS
iii) Tritiya Avarta: Uterus, fallopian tubes, etc.
 PV = Pervaginal Examination
- Manual examination
- Sparshana pariksha
- Examine all three Avartas
- Observe tenderness, consistency, mobility, pain, etc.

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प्रसूति िन्त्र

 Pittaja Granthi & Raktaja Granthi:

 Types of Breast Lumps:

1) Fibrocystic Breast Disease / Fibroadenosis

-> Intraductal pappiloma:

 Samprapti: Dosha prakopa -> Mamsa dusti -> Arbuda lakshana

 Lakshana: वृत्तिं स्थिरिं मन्दरूजिं म ान्तमनल्पमू लिं तिरवृद्ध्यपाकम् ।

 Bheda: वािे न तपत्ते न कफेन िातप रक्तेन मािं सेन ि मे दसा ि ।

 Samprapti: Dosha prakopa -> Mamsa dusti -> Arbuda lakshana

Upadrava: Raktakshaya, Pandu

Nidana: Atimamsa bhojana, Mamsa dusti

 Adhyarbuda: One Arbuda develops over a previous one.

 Dvirarbuda: Two Arbuda are growing simultaneously.

a) DCIS Ductal Carcinoma In-Situ

-> Paget’s Disease of the Nipple:

 Chikitsa: Vrana & Shopha Chikitsa, Patana, Jalaukavacharana

i) Lactational Breast Abscess

ii) Non-lactational Breast Abscess

2) Agantuja Shotha Hetu:

 Purvarupa: Ushma, Daha, Siranama Ayama (dilation of vessels)

 Samanya Lakshana:Gaurava, Utsedha, Ushma, Sira tanutvam, Lomaharsha, Vaivarnya

 Upadrava: Chardi, Shvasa, Aruchi, Trishna, Jvara, Atisara, Daurbalya

- Vamanadi Chikitsa if Dosha are excessively aggravated

2) Agantuja Shopha Chikitsa:

- Causative organism: Mainly = Staphylococcus aureus

- Sub-types: a) Infection involves breast parenchymal tissue. Lactiferous ducts are

- Incubation period: 1-2 weeks

- Complication: Breast abscess

- Management: a) Prophylactic = Thorough hand washing before each feeding.

b) Curative = Antibiotics, Analgesics, Drainage in case of abscess

- Cause: Milk stasis due to poor breastfeeding technique.

- Management: ▪ Continue breastfeeding from the affected side, otherwise

B) ii) Non-lactational Mastitis

- Signs & Symptoms: ▪ Peri-areolar pain, Tenderness, Nipple discharge

 Signs & Symptoms:

 Complications: Secondary infection with development of breast abscess.

 Investigations: Mammography, Ultrasound

 Management: Galactoceles are benign lesions which in most cases

 स्नेहन & स्वे दन

Abhyantara Snehana with Chatursneha, Badara Rasa and Triphala Kvatha is

Nadisvedana is tube fomentation in which the steam is generated by boiling the

उत्तरर्स्ि is the therapeutic procedure of administering medicinal drugs through intra-

 अधिष्ठान = िृ िीयाविब , तििीयाविब

 अयोग = प्रसावकाल, गर्ब काल

2) प्रधानकमब ▪ Early morning

3) पश्चािकमब ▪ Head low position for 30 min - 1 h.

- पूवबकमब is done to improve absorption & circulation of Aushadha Dravya.

1) पूवबकमब ▪ Required investigations

2) प्रधानकमब ▪ Aseptic measures

 उपद्रव = Infection, Ulceration, Pain, Burning sensation

 अधिष्ठान = प्रिमाविब (योतन)

Requirements: Suppository, Applicator, Soap, Water, Towel, Sanitary napkins

Inserting the suppository:

 पयािय = योतन पूरर्ण, योतन धारर्ण, कल्क धारर्ण

Anti-fungal vaginal creams, commonly used for yeast infections:

 अधिष्ठान = प्रिमाविब (योतन)

2) कफघ्न & क्लेदघ्न

 पयािय = योतनप्रक्षालन, योतनरे िन, योतनसेक, योतनपररषेक

1) पूवबकमब ▪ Required investigations

2) प्रधानकमब ▪ Aseptic measures