Mudha Garbha – Obstructed Labor, Ayurveda Perspective

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S

Mudha Garbha means obstructed fetus. When the fetus is unable to come out in the process of delivery and gets impacted in the uterus it is called mudha garbha.

Mudha = obstructed / stupefied
Garbha = fetus
Read – Anomalies, Defects In Fetus, Ayurvedic Treatment

Definition

a. The fetus which gets developed, comes abnormally or is unable to come out even after reaching the birth passage i.e. pelvis and vagina and gets stupefied and swooned due to abnormality of apana vata is called as Mudha Garbha.

b. The fetus which reaches abnormal passage, comes with different presentations, gets troubled by abnormal vayu and gets unconscious is known as mudha garbha.

c. The stupefied vayu goes astray and stupefies the fetus. This stupefied fetus is called as mudha garbha.

References

1. Sushruta Samhita Nidana Sthana.8/3
2. Ashtanga Sangraha Shareera Sthana 4/29
3. Madhava Nidana 64/3, Bhavaprakasha 70/113, Yogaratnakara Striroga Chikitsa
   Read – Bleeding During Pregnancy: Causes, Ayurvedic Treatment

Different perspectives

Since different definitions have been given to explain mudha garbha it is important to understand what exactly mudha garbha is in right terms.

Mudha explains one of the below mentioned conditions –

• Stupefied
• Unconsciousness
• Swooned
• To become bewildered
• To go in wrong direction
• Become lazy

Seeing the collective explanation by all authors, Mudha Garbha is a condition in which there is –

• Obstruction of labor
• Fetus which has gone astray, swooned up and unable to descend (get delivered)
• Obstructed movements of the fetus
• Abnormal presentation along with obstructed movement in the fetus

a. Mudhagarbha is obstructed labor due to over-growth of a part of fetus – Master Sushruta, in the definition of mudha garbha has used a term ‘vivrddha’. Vi = exaggerated, Vrddha = growth. This explains that the fetus is over sized and hence unable to descend and causes obstruction. This condition may be called as Macrosomia. Macrosomia is the over-growth of a part of a fetus. It may present in the form of hydrocephalus, ascites or congenital tumors.

b. Mudha Garbha is obstructed labor due to various kinds of mal-presentations of the fetus – Asamyak agata (Sushruta) means abnormal presentation of the fetus. Anekadha Pratipanna (Vagbhata) means fetus presenting in different ways, like mal-presentations or odd positions.

c. Mudha Garbha is obstructed labor due to abnormalities of birth passage – Apatyapatam anupraptam anirasyamanam (Sushruta) – This means that the fetus reaches the birth passages and gets obstructed at the birth canal due to abnormal birth passage. Vagbhata has clearly mentioned the word asamyak apathya patha which means ‘abnormal birth passage’. This explains mudha garbha as ‘obstructed labor due to abnormal birth passage’.  

d. Mudha Garbha is obstructed labor caused by abnormality of apana vayu leading to unconsciousness of fetus – Garbha sammohana – has been mentioned by most authors. Commentators explain the meaning of the term as ‘unconsciousness of the fetuses’. This can actually be understood as stupefaction. This is because when apana vata of the mother is imbalanced it cannot cause loss of consciousness of the fetus since the consciousness of the fetus is related to and maintained by its own balanced prana vayu.

When in a state of balance, apana vayu helps in easy delivery of the child. Therefore stimulation of uterus and its muscles, descent of the child into the birth passage and normal delivery of the child can be considered as normal functions of apana vata. From this we can infer that abnormality or imbalance of apana vata will obstruct the movement, descent and delivery of the fetus by influencing the activities of uterine muscles.

Therefore this explanation of mudha garbha explains – ‘obstruction to the descent of fetus and progress of labor due to abnormal or less contractions of uterine muscles’. This is a condition of uterine inertia.
Read – Pittaja Yoni Vyapad – Causes, Symptoms, Treatment

Gestational age at which fetus get obstructed

Specific age of the fetus wherein it causes or gets obstructed in the process of labor has not been explained in any texts of Ayurveda.

1. Sushruta has explained that abortion will occur up to 4^th month of pregnancy. Later he tells that obstruction occurs in developed or grown up fetus. On this, Dalhana opines that obstruction of delivery of fetus can occur in 5^th or 6^th month since the fetal parts become formed and solidified by this time. He also defines obstruction of fetus as ‘stupefaction of fetus having all body parts associated with mind and intellect caused by vitiated apana vata’. The development of all the body parts of the fetus gets completed in 7^th month. Therefore it is obvious that the obstruction to labor cannot occur before 7^th month. To add confusion, Dalhana has mentioned 2 kinds of obstruction in labor –

1. Prasavakalotpanna Mudha Garbha – obstruction in labor occurring during normal period / time of delivery of the child – occurs during normal delivery period, at 9^th month
2. Akala Mudha Garbha – obstruction in labor occurring during abnormal time (before scheduled time for delivery) – occurs before normal delivery time / premature labor, at 7^th month

2. Madhukosha commentary of Madhava Nidana accepts obstruction to occur during normal delivery period – 9^th month of pregnancy onwards.

3. While describing the pathogenesis of intrauterine death of fetus, master Vagbhata tells that the fetus descends from the space in between liver and spleen. The same explanation has been given by Sushruta while describing the pathogenesis of obstructed fetus. The uterus reaches this height only during 8^th month of pregnancy. Therefore the obstruction of labor occurs 8^th month onwards.

Summing up all these explanations, obstruction of labor can be considered to happen between 7^th and 9^th months of pregnancy, after 8^th month of pregnancy to be precise.
Read – Monthly Development Of Fetus – Ayurvedic perspective

Does obstruction of labor occurs in living or dead fetus?

Master Charaka tells that the pregnant woman shall be referred to a surgeon if the fetus which has died in the uterus doesn’t get delivered with medicines or mantras. This explanation resembles that of obstructed labor though Charaka has not used the term Mudha Garbha. According to this, obstruction in labor occurs only in dead fetus.

Master Vagbhata tells that the fetus which has died in the uterus when gets stupefied will be called as mudha garbha. His definition of obstructed fetus covers unconsciousness or swooning of fetus. He further contraindicates destructive surgery of living fetus. According to this, obstruction in labor can occur in both dead and living fetus. By mentioning different line of management for obstruction in labor caused by alive and dead fetus, Sushruta and other authors too have accepted that obstruction can occur in both conditions.

Causes of obstructed labor

Most authors have explained the etiology of abortion and intrauterine death of fetus together. The causes of these two conditions should be considered as etiology of obstructed labor also.
Read – Ireland Abortion Incident – Is There Any Religion Greater Than Humanity?

Below mentioned are the causes of obstructed fetus (Su.Ni.8/3) –

Sl No	Etiology for obstructed labor	Meaning
1	Gramya dharma / maithuna	Excessive coitus
2	Yana	Riding on animals
3	Vahana	Riding in carriages
4	Adhwagamana	Excessive traveling, walking
5	Praskhalana	Staggering
6	Prapatana	Falling down
7	Prapidana	Compression
8	Dhavana	Running
9	Abhighata	Trauma
10	Vishama Shayana Asana	Sleeping or sitting abnormally or in uneven places
11	Upavasa	Fasting
12	Vega Abhighata	Suppression of natural urges
13	Ati Ruksha Katu Tikta Bhojana	Use of excessive dry, hot or pungent foods
14	Shoka	Excessive grief
15	Ati Kshara Sevana	Excessive use of alkalies
16	Atisara	Diarrhea
17	Vamana	Vomiting
18	Virechana	Purgation
19	Prenkolana	Swinging
20	Ajirna	Indigestion
21	Garbha Shatana	Use of abortifacient drugs

Due to the above said etiological factors, the fetus gets detached from its bonds just like a fruit gets detached from its stalk due to trauma and falls down.

According to Master Harita – incompatible diet of mother, diseases of fetus and severe headache to the mother causes troubles to the fetus. Due to these or expulsion of fetus in oblique position or due to other reasons, the fetus dies and troubles the woman. Sometimes due to shyness or some other reasons, the vaginal passage gets constricted. In this case, the fetus approaching the constricted passage becomes obstructed.

Summary of etiological factors

The below mentioned factors may cause irregular uterine contractions or uterine inertia –

Dietetic factors – Master Harita has specified incompatible diet as one of the causes for obstructed labor. Improper diet leading to nutritional disorders may not only deteriorate the general health of mother but also influence on the contractions of uterine muscles in a bad way. Unbalanced diet is one of the causes of toxemia of pregnancy. Obstruction of labor occurs in toxemia.
Read – Ayurvedic Diet And Lifestyle For Pregnant Woman

Psychological factors – Harita has mentioned shyness or other factors causing obstructed labor. Other factors may include psychological factors like stress, fear, anxiety etc which may have strong influence on reproductive system, spasms or constriction of genital tract and also may influence contractions of uterine muscles.

Abnormalities of nervous system functions – These occur in two forms –

• Absence of contraction of uterus / uterine inertia
• Irregular / excessive uterine contraction

Ayurveda has explained abnormality of apana vata as the reason for failure of descent of fetus. The treatment for the same and also for obstruction of fetus too has been explained. This seems to be the explanation of uterine inertia. Presence of pain (shula) in the absence of labor pains (avi), feeling of stony hardness of abdomen and uterine region and tetanic spasms of uterus (makkalla) appears to be descriptions of irregular or excessive uterine contractions. Sometimes there occurs failure of dilatation of cervix due to ineffective uterine contractions. This has been described as Yonisamvrti or Yonisamvarana.

Idiopathic Causes – Ayurveda has mentioned daivayoga which can be considered as uterine inertia due to idiopathic causes.

Abnormalities of shape and size of fetus – Vivrddha Garbha explains the abnormality of size of fetus and diseases of fetus mentioned by Harita explains shape abnormalities of fetus, both can cause obstructed labor.

Abnormalities of fetus presentation – Ayurveda texts has explained about the fetus presenting abnormally, with other parts or coming down obliquely. Ayurveda has also explained various modes of fetal presentations. These are clearly the descriptions of abnormal presentations or positions of fetus explained in modern texts which can cause obstructed labor. On the other hand, Ayurveda texts have also mentioned the influence of postures of mother on the presentation or position of fetus.

Abnormalities of birth passage –

• Harita states ‘presence of abnormalities of uterus makes the obstructed labor incurable’.
• Ayurveda has explained ‘fetus reaching abnormal maternal passage’ and ‘fetus unable to come out’. These conditions explain the abnormalities of pelvis.
• Explanation of yonisamvarana / yonisamvrti refers to ‘failure of uterine cervix to dilate’.
• Spasm of bhaga explained by Harita as caused by shyness and other mental factors explain ‘perineum rigidity caused by psychogenic factors’.
• Among the symptoms of bad prognosis of obstructed labor, yonibhramsa has been mentioned. This clearly explains prolapse of cervix. Proper dilatation of cervix doesn’t take place in case of cervical prolapse. This causes obstruction of labor.
  Read – Charaka Chikitsa Sthana 30th Chapter – Yoni Vyapat

Pathogenesis of Obstructed Labor

The pathogenesis of obstructed labor is the same as that of intrauterine death of fetus (Vagbhata) and abortion (Sushruta) explained in Ayurveda.

The pathogenesis –

• The fetus gets detached from its bonds.
• The fetus later transgresses the uterus and descends down from the spaces amongst liver, spleen and bowels.
• The fetus descending between the viscera irritates and causes hyperactivity of stomach and intestines (and all visceral organs).
• As a result the Apana Vata gets mudha i.e. gets aggravated and will have abnormal movements.
• This vata eventually causes pain in flanks, upper region of urinary bladder and reproductive system. It also causes tympanites, retention of urine and various diseases.
• These events will be followed by death of young fetus due to bleeding per vagina.

Bonds = muscles and vessels attached to the uterus (Dalhana)
Read – Symptoms Of Vata Dosha Increase And Imbalance – Vata Vruddhi Lakshana

Clinical Features of Mudha Garbha

The symptoms explained in the pathogenesis of obstructed fetus shall be considered here.

• pain in flanks, upper region of urinary bladder and reproductive system / vagina
• tympanites
• retention of urine

Special signs and symptoms

Various kinds of presentations and positions of the fetus in obstructed labor are its special clinical features. Here, the fetus may engage in the pelvic cavity in one of the below mentioned presentations / positions –

• by its head – vertex presentation
• by its shoulders – transverse presentation or
• by its thighs – breech presentation

Ayurveda has explained that the obstruction of labor occurs due to abnormality of vayu. Due to this the fetus presents in numerous ways. Ayurveda texts have described the types and gati – movements / positions of obstructed labor which explain the different positions and presentations of fetus.
Read – Shoola Types, Symptoms, Treatment, Medicines, Remedies

Types, Symptoms

A. 4 types of obstructed labor as explained by Sushruta, Madhava Nidana, Bhavaprakasha and Yogaratnakara –

Sl No	Name of the type of Mudha Garbha	Presentation of the fetus	Modern comparison
1	Kila / Sankilaka	Both the hands, feet and head of the fetus are upwards and obstructs like a wedge.	The fetus presents with butts in incomplete breech with extended legs.
2	Pratikhura	In this condition, the fetus gets obstructed by its body presenting with head, hands and feet all together. This means to tell that a part of head, hands and feet present together at the vaginal opening.	This can be considered as a condition of ‘exaggerated flexion of fetus in transverse lie’.
3	Bijaka – This presents in 2 forms.	a. Fetus in this condition delivers by its head along with one hand (Sushruta).	It explains ‘prolapse of one hand in vertex presentation’.
b. It is also explained as the fetus delivering with head situated between both hands and getting obstructed by its remaining body (Madhava Nidana etc texts).	It is a case of ‘compound presentation of fetus presenting with both hands and head’.
4	Parigha	The fetus obstructs the passage just like an iron rod which is used for shutting the doors.	This can be compared to ‘shoulder presentation in dorso-anterior position of transverse lie’.

Read – Vatala Yoni Vyapad – Causes, Symptoms, Treatment

B. 7 types of obstructed labor described by Harita –

Types of Mudha Garbha	Symptoms
Eka Doshaja (Caused by single dosha)	1.Vataja	Pain in the region of urinary bladder Obstruction in vaginal passage Gurgling sound in abdomen Flatulence Pain in abdomen Breaking type of pain in body parts Sleeplessness
2.Pittaja	Pain in abdomen Fever caused by vitiation of all three doshas Thirst Giddiness Dysuria Headache
3.Kaphaja	Laziness Drowsiness Sleepiness Stillness / stiffness Flatulence Tremors Cough Tastelessness
Dwi Doshaja / Dwandvaja (Caused by two doshas)	4.Vata-Pittaja	Mixed symptoms of two doshas will be present in each case.
5.Vata-Kaphaja
6.Pitta-Kaphaja
Sannipataja (Caused by three doshas)	7.Tridoshaja	Mixed symptoms of all the three doshas will be present.

Different presentations

Mudha Garbha Gati – different presentations of fetus in obstructed labor
Master Sushruta has explained 8 gatis after mentioning 4 types of obstructed labor.

Master Dalhana opines that there may be more than 8 presentations including tiryak – transverse presentation, griva – cervical or neck presentation, jangha – thigh presentation etc.

Master Vagbhata I has explained 3 gatis. They are –

Sl No	Gati (mode of fixations)	Presentation	Modern correlation
1	Urdhwa Gati	Fetus remains very high up	Cephalo-pelvic disproportions / extension of head
2	Tiryak Gati	Head and feet are situated in both flanks of the woman.	Transverse lie
3	Nyubja	Head of the fetus is downwards and foot upwards.	Dorso-anterior position / Transverse lie

Master Vagbhata I has also described 8 presentations. He calls these presentations as samsthana.

Below given is a summation of various positions and presentations described by all authors. It also includes the 4 types of obstructed labor explained by Master Sushruta. (Ref Source: Prasuti Tantra – Premvati Tivari).

Sl No	Gati (Position, presentation)	Presentation	Modern correlation
1	Dwabhyam Saktibhyam	With both thighs	Presentation in incomplete breech
2	Abhugna eka sakthi ekena	One thigh presenting with the other thigh flexed	Footling presentation in incomplete breech
3	Spik deshena tiryak agatah	Butts in incomplete breech with extension of legs or complete breech (Kilaka)	Incomplete or complete breech
4	Urah parshva prshtanam anyatamena	Presents with chest, flanks, back or other parts (Parigha)	Transverse lie in dorso-posterior and dorso-anterior position
5	Antah parsvapavrtta shirah, ekena bahuna	One arm or head situated in flanks and delivery with one hand (Bijaka)	Hand prolapsed in transverse lie or in vertex presentation
6	Abhugna Shira Bahu Dwaya	Flexed head with both hands (Bijaka – Madhava Nidana)	Compound presentation
7	Abhugna Madhyo Hasta pada shirobhih	Presenting with both hands, legs and head together in exaggerated flexion (Pratikhura)	Transverse lie
8	Ekena Sakthna yonimukham pratipadhyate aparena payum	One foot in the vagina and the other in the anus	Rupture of lower uterine segment with perforation of colon / rectum
9	Dwaram niruddhya shiraa	Obstruction of head	Abnormal vertex presentation as POP, brow presentation or in contracted pelvis
10	Awangamukha	By face	Face presentation
11	Jathara	Abdomen presentation	Dorso-posterior position and abdomen presentation of transverse lie / cord presentation
12	Parivartita Sharira & Kubjadeha	Presentation with rotated body and with humpback	Dorso-anterior with flexed back in transverse lie
13	Tiryag gata	Transverse	Transverse lie with flexion of fetal body
14	Parswapavrtta	Presenting with flanks	Lateral delivery in transverse lie

Read – Garbhasana – Fetus In Womb Pose, Right Method, Benefits

Incurability of obstructed labor

a. Mudha Garbha becomes incurable in the presence of below mentioned conditions –

Garbha kosha parasanga – This has two meanings – over-clinging of fetus in uterus or attachment of fetus in abnormal place. The second meaning seems to be more precise. Rupture of uterus should happen if the fetus to be attached at some other place other than uterus. In some cases of obstructed labor, rupture of uterus will be seen, as a complication. Therefore garbha kosha parasanga can be equated with ‘rupture of uterus’.

Makkalla – This condition too has been explained in 2 meanings – accumulation of blood in uterus during labor before the delivery of the child (intrapartum hemorrhage) or pain arising after delivery due to the blood getting obstructed by vayu in the uterus. Since we are speaking about obstructed labor here, the first meaning suits the explanation. According to Adhamalla garbha-makkalla is a condition in which the fetus afflicted with physical and psychological diseases produces pain in the abdomen.

Yoni Samvrti / Yoni Samvarana – The vayu located in vaginal canal of pregnant woman gets aggravated due to consumption of vata aggravating foods, excessive coitus and night awakening. This vayu contracts the vaginal orifice, moves inwards, obstructs the aperture of cervix and troubles the fetus. The fetus eventually dies due to obstruction of its mouth and respiratory passages. The vayu may even kill the mother by causing tightness in her heart region, shallow expiration and obstruction to the heart. This condition can be compared to severe degree of cervical dystocia.

b. Apart from this, the below mentioned conditions mentioned by Sushruta in the gati of obstructed labor are also incurable –

• Abhugna Madhyo Hasta pada shirobhih / Pratikhura – Transverse lie
• Ekena Sakthna yonimukham pratipadhyate aparena payum – Rupture of lower uterine segment with perforation of colon / rectum

c. Mudha Garbha associated with the below mentioned conditions is also said to be incurable –

• Viparita indriyartha – hallucinations / odd sensory perceptions
• Akshepaka – convulsions
• Yoni bhramsha – uterine prolapse
• Yoni Samvarana – severe degree of cervical dystocia
• Makkalla – intrapartum hemorrhage
• Shwasa – dyspnea
• Kasa – cough
• Bhrama – giddiness

d. The mother kills the fetus and the fetus kills the mother when the below mentioned conditions are seen –

• Pravidhyati shiro – woman unable to hold her head / strikes her head repeatedly
• Shitangi – body of the mother is cold
• Nirapatrapa – mother has become shameless
• Niloddhata sira – blue veins have appeared all over the abdomen of the expectant mother

e. A woman with obstructed labor doesn’t survive when below mentioned conditions are present –

• Puti gandha mukham – have foul smell in breath
• Shula – pain in abdomen
• Nidra – excessive sleep
• Mayura griva sankasham pashyati hutashanam – sees the fire just like the neck of a peacock – blue in color
• Shuna pada – swollen foot
• Shuna mukha – swollen face
• Rakta vastra paridhana rakta malya anulepana – the woman wears red garments and garlands, uses red anointment
• Ramyate saa shayaana – smiles during sleep
• Smashanam yaa adhirohati – the woman goes towards cremation ground in dreams

f. If the uterus is diseased, fetus has slow progress or when the obstruction to the labor occurs due to constriction of vaginal canal or pelvis – the obstructed labor becomes incurable. Slow progress of the child can be considered as uterine inertia.

References

• a-d – Su.Su.33/13, Su.Ni.8/6-11 & Su.Chi.15/9
• e – Ka.Sam.Khi.10
• f – Ha.Sam.Dwi.Stha.4/41
  Read – Anomalies, Defects In Fetus, Ayurvedic Treatment

Sanskrit Verses

Treatment of Mudha Garbha

Detailing the qualifications of the accoucheuse, Bhavaprakasha and Yogaratnakara treatises opine that the woman having the experience of conducting many difficult labors and have good command on the knowledge of instruments and books should handle case of obstructed labor. She should also be wise, bold and gentle in handling the condition.

Treatment principles

The below mentioned treatment principles shall be included in treating Mudha Garbha in general –

• treatment of placenta retention
• treatment of dead fetus explained by Charaka
• surgical procedures – done by expert surgeons
• fetus shall be delivered with the help of massage (Harita)
• use of mantras prescribed in Atharvaveda
• use of medicated enemas
  Read – 15 Precautions And Benefits Of Massage In Pregnancy

Delivery of live fetus

Every effort should be made to deliver the child as long as the fetus is alive. Chyavanamantra should be recited if the delivery does not take place. The medicines prescribed for expulsion of retained placenta should be used.

External genitalia and vaginal canal should be irrigated with lukewarm water. Later it should be anointed with jaggery, kinva – seeds of herbs used for fermentation and salt. Vagina should be filled repeatedly with this combination. Alternatively gum of shalmali – Bombax ceiba mixed with mucinous substances obtained from atasi – Linum usitatissimum shall be used for filling the vagina.

Below mentioned herbs shall be used for quick and easy delivery of the child (Ha.Sam.Tr.Sth.52/18-28) –

• Root of Langali – Gloriosa superb rubbed with hot water and made into paste should be applied over the navel region.
• Roots of Bala – Sida cordifolia, Suryakanti – Helianthus annuus and Somavalli – Sarcostemma acidum / Psoralea corylifolia ground with kanji – fermented drink should be applied over the abdomen and navel.
• Roots of Bhiru – Asparagus racemosus, Bhunimba – Andrographis paniculata, Vartaki – Solanum indicum, Pippaliyaka – Piper longum, Yavani – Trachyspermum ammi, Agra & Vacha – Acorus calamus should be rubbed with water, made into paste and applied over the navel.
• Roots of Langali – Gloriosa superb and Devadaru – Cedrus deodara, Tumbika – Diospyros malabarica / Diospyrus exsculpta and Koshataki – Luffa acutangula should be pestled and applied.

The following mantras advised by Harita shall be recited (translations of the mantras are given here) –

1. ‘A Rakshasi – female demon named Surasa lives in the northern bank of Himalaya. By hearing the sounds of her ornaments / anklet, the woman delivers easily’.
2. Use of water of milk treated with hymns including ‘An hri calaya calaya swaha…’ facilitates easy delivery of the child.
3. Hymns like ‘An Hram…Hrah…’ etc should be written on the upper part of Bhurjapatra – Baetula utiles / Streblus asper. This leaf should be kept under the bed of the expectant woman or showed to her.
4.  ‘On the banks of Ganga River there lives a she-crow. Kakarudra tells that the water dropped from her feathers given immediately to the woman brings about easy delivery’. When the physician gets tired of reciting this hymn, water treated with the same hymn should be given to the woman for drinking. The woman then delivers in the same way as the she-crow lays the eggs without pain or difficulty.
   Read – Analysis Of Effect of Mantras On Health And Nadi

Herbs prescribed in Yogaratnakara too help in delivery of the living fetus –

• Asuri – Brassica juncea, Hingu – asafetida and Saindhava – rock salt
• Feces of mare dissolved in kanji and strained through a cloth, mixed with rock salt, ugra – Acorus calamus, asuri – Brassica juncea and tila taila – sesame oil should be given for oral consumption. This helps in delivery of obstructed fetus presenting abnormally.
• Ground roots of parushaka – Grewia asiatica or sthira – Desomodium gangeticum should be applied over the umbilicus, urinary bladder region and vulva. This helps in expulsion of the obstructed fetus.

Use of Matangividya – According to Kashyapa, when the woman having difficult labor listens to Matangavidya referred under varanabandha, delivers easily.

Treatment of obstructed labor caused by doshas

Sl No	Dosha involvement in obstructed labor	Treatment
1	Vata	a.Mardana – rubbing / kneading b.Abhyanga – massage c.Alpa swedana – mild sudation d.Panchakola yavagu – gruel prepared from Panchakola
2	Pitta	a.Shitanna-Shita jala – consumption of cold water after consuming cold food b.Shakadi vyanjana – vegetables and other cold edibles c.Yashtika – Glycyrrhiza glabra with milk
3	Kapha	a.Decoction prepared with Trikatu, Triphala, Kushta – Saussurea lappa, Lodhra – Symplocos racemosa, Vatsaka – Holarrhena antidysenterica and flowers of Dhataki – Woodfordia fruticosa mixed with jaggery
4	Rakta-Pitta – disorders of blood and pitta in obstructed labor	Decoction of Murva – Marsdenia tenacissima, Cinca – Tamarindus indica, Vastukarni, Rodhra – Symplocos racemosa, Nilika – Indigofera tinctoria, root of Karkandu – Ziziphus mauritiana, Saurashtri & jaggery should be given. It cleanses the gut.

Delayed treatment in dead fetus

When the dead fetus in obstructed labor is neglected or its treatment delayed:
The wise physician should treat the dead fetus in obstructed labor immediately without neglecting the condition even for a moment. If not treated promptly, the dead fetus will kill the mother by producing asphyxia just like an animal after over-eating would die due to asphyxia caused by distension of belly.

Difficulties encountered during extraction of garbha shalya – dead fetus which has become a foreign body

In comparison to the extraction of any impacted foreign body, extraction of dead fetus which has become a foreign body is said to be most difficult and complicated one.

In this condition every manipulation should be done with hands on the basis of palpation without visualizing anything. The dead fetus should be removed / extracted from in between the vagina, liver, spleen, bowels and uterus.

All the below mentioned acts of manipulation should be done with only one hand taking care not to injure the mother and fetus (if the fetus is alive) –

• Utkarshana – pulling the fetus upwards which has come too much down
• Apakarshana – dragging the fetus downwards which has moved too much upwards
• Sthanapavartana – rotation or cephalic version
• Udvarthana – pushing the face upwards
• Utkartana – cutting
• Bhedana – perforation
• Chedana – excision
• Pidana – compression or pressure application
• Rujukarana – straightening
• Darana – incision

Preparation for surgery

Surgery should be done on empty stomach. When the abdomen is full it may become difficult to insert the instruments. The woman may die and vata also gets aggravated.

According to Arunadatta food is contraindicated before surgery but wine shall be given. Hemadri has contraindicated both.

Before extracting the fetus in obstructed labor, consent of the guardian of the woman shall be obtained.

Later, the woman should be placed in proper position and surgery should be done.

Once the fetus is dead or when medicinal treatment fails, extraction of the fetus shall be done by keeping the woman in supine position with flexed thighs. Her hips should be elevated by keeping a thick pad of clothes beneath it. The vagina and hands of the expectant woman should be lubricated using the mucinous substance extracted from Dhanwana – Grewia tiliaefolia, Shallaki – Boswellia serrata, Shalmali – Bombax ceiba and ghrta – ghee. After these preparations, the fetus should be extracted by inserting the hands into the vagina. This position resembles the lithotomy position explained in the modern texts.

According to master Harita – the woman should be seated over a circular thick pad specially prepared for this process. She should sit with extended thighs during extraction of dead fetus in obstructed labor.
Read – Multiple Pregnancy, Twins Ayurveda Concept – Bahvapatya, Yugma Garbha

Manual extraction of fetus

1. When the fetus presents with both thighs it should be extracted in the same or downward direction.
2. When the fetus presents with only one thigh the physician should first deliver the other thigh and later extract the fetus.
3. When the fetus is presenting with the butts, the physician should dislodge the butts and push them upwards. Later both the thighs of the fetus should be brought downwards and the fetus should be delivered.
4. When the fetus presents in oblique or transverse position, the back or hips of the fetus should be pushed upwards, the head brought downwards to the passage, should be straightened and the fetus extracted (cephalic version).
5. When the fetus presents with the head moved to the lateral side i.e. shoulder presentation, the shoulder of the fetus should be dislodged, pushed upwards, bring the head to the birth passage and the fetus extracted (cephalic version).
6. When the fetus presents with both arms, the arms should be pushed upwards by pressing the shoulder region, the head brought down to the birth passage and the fetus extracted.

According to Master Harita – The woman should be made to sit on the circular pad with abducted thighs. Her back should be compressed gently and the fetus brought downwards into the abdomen. When the fetus reaches the vaginal passage, the physician should insert his hand lubricated with sesame oil and water into the vagina. The vagina should have been already lubricated with the same combination of sesame oil and water. The neck of the fetus should be grasped gently with the index finger and thumb and the fetus extracted.

Indication for surgery

a. In the last 2 types of gatis of mudha garbha explained by master Sushruta, manual extraction of fetus is not possible. In these conditions surgery should be done (Su.Chi.15/9). These conditions are –

• Fetus presenting with both extremities and head together with body flexed in mid back
• Fetus presenting with one foot in vagina and the other foot in anus

b. Surgery should be sought for when the fetus inside the uterus is dead (Bhavaprakasha, Yogaratnakara).

c. Master Kashyapa has mentioned 2 conditions of pregnancy (while explaining the bad prognosis of pregnancy) wherein surgery will be needed –

• A woman, whose nose assumes the shape of a crow’s beak, have drooped eyelids and emits smell of shakuna – bird of prey
• A woman who emits the smell of goat or horse, has become white and wishes to eat peacock’s meat

Effect of decapitation and other procedures of extracting living fetus in obstructed fetus

When the fetus is alive, it should never be split or cut. When this is done, the fetus not only dies but also kills the mother.

The conditions becomes troublesome and lethal to mother and fetus when it cannot be extracted by hand. Master Sushruta opines of not wasting time and advices to cause expulsion or delivery of fetus if the condition worsens. Thus when medicines and manual extraction doesn’t work, and if the woman’s condition is getting worse, the delivery should be carried out at the earliest even if it demands splitting or destruction of the living fetus. Thus, in emergency conditions the living fetus can also be destructed.
Read – Shastra – Surgical Instruments Of Ayurveda: Astang Hriday Sutrasthana 26

Surgical procedures

Before performing surgery for obstructed labor, the surgeon should take care to protect the life of the woman. After ensuring this, he should split or cut the part of the fetus which is obstructing the passages. The wise surgeon should use mandalagra – rounded or circular knife or anguli shastra – finger knife to cut the fetus. Vriddhipatra – kind of lancet should not be used since it is a very sharp edged instrument and can cause maternal death due to injury.

The surgeon should first assure and encourage the woman. Later with the help of mandalagra shastra and anguli shastra he should perforate the head and extract the flat bones of the skull. He should then grasp the chest, axilla, chin or palate with shanku i.e. hook and extract the fetus. Perforating the head and removal of head bones can be correlated with craniotomy. If the head cannot be perforated, the socket of the eye or temporal region should be perforated and the fetus should be extracted.

When the obstruction is caused by fixation of shoulder, the arm should be cut from the shoulder region, delivered and the fetus should be extracted. When the obstruction happens due to the abdomen being filled up by vata and when the abdomen gets distended like a leather bag filled with water, the abdomen should be split (perforated). The fetus should be extracted only after the abdomen becomes soft due to protrusion of intestines.

When the obstruction occurs due to fixation of hips or thighs, the surgeon should split the hip bones and the fetus extracted.

In short, whatever part of the fetus causes obstruction should be cut or split and the fetus extracted.
Read – Procedure of surgical operation: Ashtanga Hrudaya Sutrasthana 29

Management after fetus extraction

After extracting the fetus the following measures should be administered –

1. The placenta should be delivered.

2. The woman should be irrigated with hot water. Later she should be given massage with oil. A tampon of fat, preferably medicated oil should be placed in vagina. These measures will help in making the vagina soft and the pain subsides.

3. The below mentioned medicines should be used –

a. Krshnadi Churna – Powder prepared with the below mentioned herbs should be given mixed with oil –

• Krshna – Piper longum
• Krsnamula – Roots of Piper longum
• Shunti – Zingiber officinale
• Ela – Elettaria cardamomum
• Hingu – Ferula narthex
• Bharngi – Clerodendrum serratum
• Dipyaka – Apium graveolens
• Vacha – Acorus calamus
• Ativisha – Aconitum heterophyllum
• Rasna – Pluchea lanceolata
• Chavya – Piper retrofractum

This powder relieves pain and rigidity of vagina and flanks. It also brings about excretion of blood and moisture etc. Decoction or paste of these herbs can be used. All these formulations may be used without ghee also.

b. Dipyakadi Churna / kalka / kwatha – Powder, paste or decoction of the below mentioned herbs should be used with ghee to bring about excretion of doshas or relief from pain –

• Dipyaka – Apium graveolens
• Ativisha – Aconitum heterophyllum
• Rasna – Pluchea lanceolata
• Hingu – Ferula narthex
• Ela – Elettaria cardamomum
• Panchakola

c. Shirishadi Kwatha – Decoction of Shirisha – Albizia lebbeck and Kakubha – Terminalia arjuna should be held in mouth as gargle. Tampon soaked in the same decoction should be placed in vagina.

d. Bala Taila – This should be used in the form of vaginal irrigation, tampon, massage, enema and with diet to suppress the vayu. Similarly Shatapaka Bala Taila may be used.

The above mentioned formulations should be given for 3, 5 or 7 days. In the morning medicated ghee or oil should be given for 10 days. In the evening asava and arishta should be given for the same number of days. For the next 10 days milk processed with vata mitigating herbs should be given followed by meat soup for the next 10 days. This will cover a regimen of 30 days. After this, diet which is light, congenial and unctuous should be given in little quantity along with sudation and use of bala taila (for all purposes mentioned above) for the next 4 months. She shall avoid anger during this period. After relief from complications and after gaining strength and complexion within these 4 months she should discontinue this regimen and enjoy normal life.

4. Dealing with complications – Complications occurring during this period should be managed with appropriate measures.

5. Mrta Garbha Chikitsa – The treatment principles and methods described by master Charaka for the treatment of intrauterine dead fetus shall be used in this condition.

6. Swedana – Use of sudation is beneficial in this condition. This is useful mainly for those who are free from complications.

7. Use of cold water is beneficial.

laparotomy or cesarean section

It is called Udara Patana. If the quivering of abdomen persists even after the woman being dead during labor, the abdomen should be opened immediately and the fetus extracted. Master Dalhana further clarifies that the fetus should be removed by laparotomy within 2 ghatis or 1 muhurta (48 minutes approximately). If not done, the fetus will die. So this process is applicable for the pregnant woman who has died at full term i.e. in the 9^th month. Vagbhata has said to carry this procedure of opening the abdomen if there is quivering of abdomen over the region of urinary bladder (supra-pubic region). Commentator Indu tells that the laparotomy should be performed over the bladder region.
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