1. What data in particular will be shared?
   Response - Individual participant data that underlie the results reported in this article, after de-identification (text, tables, figures, and appendices).
   


2. What additional supporting information will be shared?
   Response -  Study Protocol
   Response - Clinical Study Report
   
   
3. Who will be able to view these files?
   Response - Researchers who provide a methodologically sound proposal.
   


4. For what types of analyses will this data be available?
   Response - For individual participant data meta-analysis.
   


5. By what mechanism will data be made available?
   Response - Proposals should be directed to [payalbichave15@gmail.com].
   


6. For how long will this data be available start date provided 01-04-2025 and end date provided 01-04-2026?
   Response - Beginning 9 months and ending 36 months following article publication.
   


7. Any URL or additional information regarding plan/policy for sharing IPD? 
   Additional Information - nil

RESEARCH QUESTION

 What is the effect of Badarodakadi Asthapana Basti followed by Madhuraushadhi Siddha Tail Anuvasana Basti with Yoni Pichu for Sukhaprasava.

HYPOTHESIS

Badarodakadi Asthapana Basti followed by Madhuraushadhi Siddha Tail Anuvasana Basti with Yoni Pichu have a significant effect for Sukhaprasava

 NULL HYPOTHESIS (H₀)

There is no effect of Badarodakadi Asthapana Basti followed by Madhuraushadhi Siddha Tail Anuvasana Basti with Yoni Pichu for Sukhaprasava .

ALTERNATIVE HYPOTHESIS (H₁)

There is significant effect of Badarodakadi Asthapana Basti followed by Madhuraushadhi Siddha Tail Anuvasana Basti with Yoni Pichu for Sukhaprasava.

INTRODUCTION:  

    In a woman’s life, motherhood is a crowning act. Every woman tries to enter in this new world of mother with minimum pain, operative aids and complications. As child bearing and delivery are physiological phenomenon and any abnormality in courses of labour can affect women health not only for that time being but also through out her life. That’s why Acharya have given specific importance to the Garbhini and compared her with the pot filled with oil, as slightest oscillation of such pot causes spilling of oil, similarly slightest excitement to the pregnant women can initiate pathological state. Acharya Kashyapa also stated that during Prasava avastha, “Her one foot is in the house of ‘Yama’ (the god of death) and other on this side (i.e., she can die at any moment).

Ensuring healthy and safe motherhood with foremost care to every pregnant woman is the outright responsibility of an obstetrician. So, to provide proper attention during pregnancy and delivery the concept of ante natal care as Garbhini paricharya is very explicitly described in ancient literatures which promote easy parturition and healthy progeny. That’s why for good health of mother and baby, Sukhprasava is important. The word Sukhprasava means bringing (or having brought) forth easily or happily.     

The term ‘prakrit  prasav ’ includes:

 Swabhavh  -  spontaneous onset

 Upasthith kala - at term

 Avaksira  -  cephalic  presentation

 Swabhawik kal - without undue prolongation

 So at the onset of labour  the  foetus  gets  turned  &  comes  forward  due  to the  action of  prasooti marut  and  then  is  expelled  out  through  apathyapath  this  is  termed  as  normal labour.As  per  Ayurveda  the  ‘Apaan  vayu’  plays  an  important  role along with ‘Vyana vayu’ in act of contraction and relaxation of uterus and in expulsion of foetus. Vyana  vayu  is  essential  for  contraction  &  relaxation  of  myometrium  and  due to its effect apana vayu becomes active to expel the Garbha outside the garbhashaya.  To  keep  this  vayu  in  balanced  state,  Acharyas  have  advised  the administration of Asthapana basti,  Anuvasan  basti,  Pichu .  Vayu  is  most  likely  to  be vitiated  during  pregnancy,  and  it  is  described  that  there  is  no  other  remedy  more beneficial  than  administration  of  ‘Basti’  particularly  in  affliction  of  vayu as basti is considered as the paramoushadhi of vata. 

Need of the Study

•       The  incidence  of  cesarean  section  is steadily rising (As per National Family Health survey NFHS the trend of c section deliveries in India has been on rise i.e.21.5 percent in 2019-21) because of increased safety of the operation due to improved anaesthesia, availability of blood transfusion and antibiotics, also its a painless mode of delivery .

•       Normal delivery is generally preferred over cesarean  section because  it can lead to a quicker recovery for the mother, reduced risk of infection, and fewer complications. 

•        So to ensure  maternal  and  fetal  wellbeing and  to  bring  about  normal  vaginal  delivery and to reduce complications due to C-sections  Asthapan basti  followed by Anuvasana  basti   and  Yoni pichu  can  play  an  important  role  in  normalizing  the  Apan vayu  at  the  time  of  child  birth and  provide  a  safe passage  to  the  passenger.

 This study aims to highlight the fact that the   principles  and  formulations  regarding  striroga and  prasuti  tantra  mentioned  in  Ayurvedic  texts  stand  invulnerable  in  this  present  era  and their  importance  cannot  be  neglected

REVIEW OF LITERATURE:

CLASSICAL REVIEW:

" In 8th month of pregnancy due to hormonal effect and Kapha Vata prakopa backache, constipation are very common problems. So Acharyas have mentioned Anuvasan and Aasthapan Basti in 8th month in Garbhini paricharya containing drugs mainly Kapha and Vata shamak. This Basti regulates Vata and clear the retained feces. Due to movement of vayu in its right direction, it delivers the baby without difficulty and remains free from complications.

   According to Sushruta -

Aasthapan Basti:3 Decoction of badar is mixed with bala, atibala, shatpushpa, palala, milk, curd, oil, salt, madanphala, honey and ghrita.  

 Anuvasan Basti: Oil medicated with milk and decoction of madhur group drugs are mentioned in Anuvasan Basti.

 Yonipichu  (vaginal tampon):  Yonipichu  is the application of  sterile swab soaked in medicated oil or decoction into the vagina.

DRUG REVIEW

Ingredients of madhuraushadh siddha tail -

MODERN REVIEW

NORMAL LABOUR :

Series of events that take place in the genital organs in an effort to expel the viable products of conception (fetus, placenta and the membranes) out of the womb through the vagina into the outer world is called Labor.

 It may occur prior to 37 completed weeks, when it is called the preterm labor.

CRITERIA OF NORMAL LABOR (EUTOCIA):

Labor is called normal if it fulfills the following criterias.

(1) Spontaneous in onset and at term.

(2) With vertex presentation.

(3) Without undue prolongation.

(4) Natural termination with minimal aids.

(5) Without having any complications affecting the health of the mother and/or the baby.

CAUSES OF ONSET OF LABOR

The precise mechanism of initiation of human labor is still obscure. Endocrine, biochemical and mechanical stretch pathways as obtained from animal experiments,

however, put forth the following hypotheses.

1.Uterine distension: Stretching effect on the myometrium by the growing fetus and liquor amnii can explain the onset of labor at least in twins or polyhydramnios.

2. Fetoplacental contribution: Cascade of events activate fetal hypothalamic-pituitary-adrenal axis prior to onset of labor �’ increased CRH �’ increased release of ACTH �’ fetal adrenals �’ increased cortisol secretion �’ accelerated production of estrogen and prostaglandins from the placenta.

3. Estrogen:  Increases the release of oxytocin from maternal pituitary.

— Promotes the synthesis of myometrial receptors for oxytocin and prostaglandins.

— Increases the excitability of the myometrial cell membranes.

4. Progesterone: Cortisol inhibits the conversion of fetal pregnenolone to progesterone. Progesterone levels therefore fall before labor. It is the alteration in the

estrogen : progesterone ratio.

5.Prostaglandins: Prostaglandins are the important factors, which initiate and maintain labor. The major sites of synthesis of prostaglandins are—amnion,

chorion, decidual cells and myometrium.Synthesis is triggered by—rise in estrogen level,glucocorticoids, mechanical stretching in late pregnancy, increase in cytokines (IL–1, 6, TNF),infection, vaginal examination, and separation or rupture of the membranes.

6. Oxytocin and myometrial oxytocin receptors:  (i) Large number of oxytocin receptors are present in the fundus compared to the lower segment and the

cervix. (ii) Receptor number  and senitivity increases during pregnancy reaching maximum during labor. (iii) Oxytocin stimulate synthesis and release of PGs (E2 and F2α) from amnion and decidua. Vaginal examination and amniotomy cause rise in maternal plasma oxytocin level

(Ferguson reflex). Fetal plasma oxytocin level is found increased during spontaneous labor compared to that of mother. Its role in human labor is not yet established.

STAGES OF LABOR - Conventionally, events of labor are divided into three stages:

1.First stage:

 It starts from the onset of true labor pain and ends with full dilatation of the cervix. It is, in other words, the “cervical stage” of labor. Its average duration is 12 hours in primigravidae and 6 hours in multiparae.

2.Second stage:

It starts from the full dilatation of the cervix (not from the rupture of the membranes) and ends with expulsion of the fetus from the birth canal. It has got two phases—

3.Third stage:

 It begins after expulsion of the fetus and ends with expulsion of the placenta and membranes(afterbirths). Its average duration is about 15 minutes in

both primigravidae and multiparae.

4.Fourth stage:

 It is the stage of observation for at least1 hour after expulsion of the afterbirths. During thisperiod maternal vitals, uterine retraction and any vaginal

bleeding are monitored. Baby is examined.

MECHANISM OF NORMAL LABOR

DEFINITION: The series of movements that occur on the head in the process of adaptation during its journey through the pelvis is called mechanism of labor.

MECHANISM: In normal labor, the principal movements are:

(1) engagement,

(2) descent,

(3) flexion,

(4) internal rotation,

(5) crowning,

(6) extension,

(7) restitution,

(8) external rotation, and

(9) expulsion of the trunk.

PREVIOUS WORK DONE

OUTCOME OF THE CITED STUDIES :

All the previous trials reported a positive outcome of the Anuvasana basti /or Yoni pichu/Asthapana basti in ninth month or during labour .It promotes normal vaginal delivery with reduction in duration of labour lesser need of induction and augmentation of labour .bishops score was more favourable in patients where vaginal tampon of medicated oil was given.

OBJECTIVES:

The present research trial has been undertaken with the following objectives

PRIMARY OBJECTIVES: 

1.     Assessment  of effect of Badarodakadi Asthapana Basti followed by Madhuraushadhi Siddha Tail Anuvasana Basti and Yoni Pichu  on Sukhaprasava through bishop’s  score.

SECONDARY OBJECTIVES

1.     Assessment of effect of the given intervention on  APGAR Score of the baby.

.

 METHODOLOGY

Screening

                                              

screeniscngs                     enennkhdgdijrollmenthh

Enrollment

Allocation (n=87)

Baseline  evaluation (ANC profile)

Administration of Badarokadi Asthapana Basti followed by Madhuraushadhi Sidhha Tail Anuvasana Basti and Yoni Pichu

Evaluation post follow

Data analysis on interpretation

 

PATIENT SETTING

 Patients will be selected from the O.P.D and I.P.D of the Prasuti tantra and Striroga department, All India Institute of Ayurveda, New Delhi, irrespective of occupation and religion.  Patients will be selected strictly as per the inclusion criteria given in the Proforma specially designed for the study and recruited into trial after obtaining voluntary consent.

SAMPLE SIZE:

Proposed study is to assess the effect of Badarodakadi asthapana basti with madhuraushadhi siddha anuvasan basti  with pichu .Study aims to promote the occurence of normal vaginal delivery.As per data available in earlier studies , Bishops score was found to be favourable in 78% of cases,assuming it to be 90% in this study with  80% power, 5% level of significance and two sided test, the calculated sample size is 79 in one  group .Assuming 10% drop outs, we will take 87 cases in the study.

SELECTION OF PATIENTS

 A written and informed consent will be taken from the patient before the commencement of the treatment. The  study  will be conducted  on  Pregnant  females  fulfilling  all  the  inclusion  &  exclusion criteria  visiting    P.G.  Department  of  Prasuti  and  Striroga  of All India Institute Of Ayurveda ,New delhi.

CRITERIA FOR SELECTION OF PATIENTS

Inclusion  criteria

·       Primigravida of  36-38 weeks of age group between 20-35 years.

·       Normal fetal presentation at term.

·       Normal pelvic measurement (adequate pelvis). 

·       Patients willing to give written informed consent

·       ICD-10-CM DIGNOSIS CODE O80 Encounter for full-term uncomplicated delivery.

Exclusion  criteria

·       Patients having  cepholopelvic disproportion, malpresentation, abnormal size of foetus, contracted pelvis.

·       Patients having systemic  diseases like  tuberculosis, jaundice, heart diseases, epilepsy  etc.

·       Patients having  polyhdraminos, pre-eclamsia, eclampsia, and  IUGR.

·       Multiple  pregnancies.

·       Malignancy  of  genital tract.

·       Pelvic  masses causing  obstruction &  vaginal obstruction (adhesion  &  stenosis)

·       Pregnant women  who are  unsuitable for basti treatment ( basti ayogya )

INVESTIGATIONS:                

Following investigations will be carried out at All India Institute of Ayurveda,Delhi

Routine Investigations :-

•       Hemogram, Blood Group, RBS, Urine- Routine and Microscopy, Viral Markers, Thyroid Profile, S.Urea,  S.  Creatinine,  LFT,  RFT,  CRP , Coagulation profile.

•       USG (Trimester Wise)

Other  investigations :-

 ECG,  2D Echo  will be    advised  in suspected cases to rule out   other  specific diseases .

DRUG PROCUREMENT

SOURCE OF DRUG COLLECTION:

   Raw drug will be procured from authentic sources. Identification and quality standardization will be done.

Method of preparation

Asthapan basti - will be prepared as per the classical reference given in the charak samhita.

Madhuraushadh sidhha tail :  In  this  study  5  drugs  guduchi,  ashwagandha  yashtimadhu  bala  atibala   are  selected  from  Madhura Skandha    of  Vimana-Sthana-8.  These  drugs  are  selected  due  to  their  easy  availability & expected  high  degree  of  clinical  effects.  For  Moorchhana  of  Tila  Taila  reference  will be taken  from  Bhasajyaratnavali-Jwararogadhikar  Adhayay.  After  Moorchhana  of  TilaTaila,  Madhura  Aushadha  Sidhha  Taila  will be  prepared  with  Taila  Paka  Vidhi  by  adding these   drugs  to  Moorchhita  Tila  Taila.  The  Taila  will be prepared in pharmacy of All India Institute of Ayurveda New Delhi.

QUALITY CONTROL AND STANDARDIZATION PARAMETERS FOR  MADHURAUSHADH SIDHHA TAIL  :

INTERVENTION CHART

^{" SOP of " Aasthapan basti}

^{BASTI (MEDICATED ENEMA)}

    Bastikarma is the procedure by which the medicines in suspension form are dministered  through rectum or genitourinary tract using bastiyantra.It is the most appropriate remedial procedure for vatadosha.

Poorvakarma

1. Probable benefits and risks of procedure will be explained to patient.

2.  Patients will be advised to get relieved of their urges of defecation and micturition

3. Anal region will be cleaned with a cotton piece soaked in plain lukewarm water

^{Pradhankarma :}

    The  patient is asked to lie on left side drawing up the right leg and straightening of  the left leg.

^{1.          Apply little  quantity of oil on patient’s anus and  nozzle of bastiyantra.}

^{2.          The nozzle is gently inserted into the anal canal upto a specific length and bastiputak containing mixture is pressed with uniform pressure.The pressure is continued till only small quantity of fluid remains in the bag.}

^{3.          Then the nozzle is removed gently and the patient is allowed to lie down in supine position till he fills urge to excrete.}

^{4.          The basti dravya along with faeces normally comes  out  within  10 minutes when  a  full dose of  Niruha basti is given.  The maximum time specified for retention of  bastidravya is  48 minutes. After  evacuation  of  the  bowel,  the patient may take hot water  bath  and  semi  solid diet.  Usually Niruha bastis are  not to be given alone. Wherever required,  Niruha basti must be given  alternatively  with  Snehabasti.}

^{2. SNEHA BASTI (OIL ENEMA):}

^{Administration of medicated oil through anal route is called sneh basti.The dosage from anal route may vary from 60ml to 240ml according to doshika predominance,disease condition/patient’s condition.}

^Procedure:

^{Sneha is administered in similar manner as niruha basti.As it is a retension enema,the contents should be allowed to retain inside for a minimum period of three hours .}

^.

Pashchatkarma :

After the drug has been injected, the waist and foot end should be raised to lift the trunk, in order to facilitate withholding of the drug as long as possible,the buttocks should be patted for maximum retention. Finally, the patient is directed to discharge his urges in Utkataasana (squatting position).

Dose:

·       The dose is to be manipulated according to the contemporary period

·       Niruha Basti: 480 ml/Basti

·       Anuvasana Basti:. 60ml /Basti

Kala:

·       Niruha Basti should always be given empty stomach or when the previous food has been digested but the appetite is not evoked.

·       Anuvasana Basti on the contrary, should never be administered before meals.

Pratyagaman kala:

The time period in which the Basti Dravyas return back is Pratyagaman Kala. The maximum Pratyagamana Kala for Niruha Basti has been assigned as one Muhurta (app. 48 mins.)

 For Anuvasana Basti, however, the maximum time limit is three Yaam (12 hrs). For Niruha Basti, if Pratyagama doesn’t occur then Phalavarti or Tikshna Basti may be introduced.

Yoni pichu:

All procedures to be done under all aseptic precautions.duration of procedure 7days minimum.

Equipments required: autoclaved pichu,sterile gloves,sterile cotton swabs.

Procedure :

1.     ask the patient in supine position with knees flexed.

2.     Clean vulva and vagina with antiseptic solution.

3.     Sterile pichu soaked in medicated ghee/oil should be taken and has to be inserted in vaginal canal with tail lying outside vagina.

4.    Guide patient to take out the pichu after 2 hrs or until urge of urination.

Assessment Criteria-                                                                                                        

 The clinical result will be  assessed by observing whether the pregnant woman will have Sukha and Nirupadrava Prasava or not and for that the following parameters will be  adopted.

• Bishop’s Score
• Labour progress according to Partogram
• Total duration of labour
• Duration and frequency of uterine contractions
• Fetal weight by USG
• Mode of delivery
• Onset of labour

§  Induction/Augmentation required or not required

A.Grade-0

Onset of Labour - Spontaneous

Partogram - Before Alert Line

Uterine Contractions - Normal Pattern

Type of Delivery - Spontaneous Vaginal Delivery without Episiotomy

Grade-I

Onset of Labour - Spontaneous

Partogram - Before Alert Line/ Between Alert Line &Action Line

Uterine Contractions - Normal Pattern

Type of Delivery - Spontaneous Vaginal Delivery with Episiotomy or with perineal tear

Grade-II

Onset of Labour - Induced

Partogram - Before Alert Line between Alert Line &Action Line

Uterine Contractions - Normal Pattern/Irregular Pattern

Type of Delivery - Spontaneous Vaginal Delivery with or without Episiotomy.

Grade-III

Onset of Labour - Spontaneous/Induced

Partogram - After Alert Line

Uterine Contractions - Irregular Pattern

Type of Delivery - L.S.C.S.

B. Duration of Uterine contraction :    

0 = > 60 Seconds   

1 = 46 – 60 seconds   

2 = 31 – 45 Seconds  

3 = < 30 Seconds

 Frequency Of uterine Contraction : 

0 = 4 contractions /10 Minutes

1 = 3 contractions /10 Minutes

2 = 2 Contractions /10 Minutes

3 = 1 Contraction /10 Minutes

C. Bishop’s Score :

0 = 10 – 13 Score

1 = 7 – 9 Score

2 = 4 – 6 Score

3 = 1 – 3 Score

BISHOP’S MODIFIED SCORING:

Each components is given a score of 0-2 or 0-3. The highest possible score is 13. 

A - severely depressed         0-3

B - moderately depressed    4-6

C- excellent condition         7-10

Pain threshold during labour:                                             Score

Bearing down efforts: (Pravahana)

After Pains :

Post partum bleeding:

WITHDRAWAL CRITERIA

·       If there is any complication.

·       If the condition of the patient deteriorates during the trial.

·       Patient not willing to continue in the study or incompliance for 3 or more than that days .

RESCUE MEDICATION & ADR

If there is any occasion of adverse effect, additional pharmacological drugs will be prescribed in consultation with the contemporary medical practitioners or other ayurvedic drugs will be administered in consultation with the experts in the field.

If Any adverse drug reaction observed By Doctor or Patient it will be recorded and  reported to Pharmacovigilance center, AIIA,New Delhi.

ETHICS COMMITTEE CLEARENCE:

Study will be started after getting clearance from Institutional Ethics Committee., and after CTRI Registration

Reporting of ADR (Adverse Drug Reaction), if any observed by doctor/patient will be reported to the specific authority. Pharmacovigilance center, AIIA,New Dlhi

STUDY MONITORING:

The study will be monitored at Department of Striroga evam Prasuti Tantra,All India Institute by Guide, Co-guides and faculties of the department.

PATIENT COMPLIANCE PROTOCOL :

·       Participants will be provided with a compliance chart which they will be required to fill every day.

·       Participants will be monitored on regular basis through call/whatsapp.

·       Minimum 80% compliance is must to continue the study.

·       Treatment plan,its importance,potential side effects,expected outcomes will be explained to the participants in the way they can understand.

CONFIDENTIALITY:

·       The information that we collect from the study project will be kept confidential.

·       Information on your health and mental status(as the case may be) that will be collected while conducting the research will be kept confidential and no one but the researchers will be able to find it also all the information about the participant will be coded.

·       Only the All India Institute of Ayurveda Ethics Committee and other regulatory bodies under Government of India law would have access to these records.

TRANSLATIONAL VALUE O F THE RESEARCH :

•       Present study could help validate and promote the use of this traditional medical practice like basti and vaginal tampon in modern obstetrics

•       It could reduce the occurrence of surgical complications in childbirth which might have broader implications for maternal and infant health .This could translate into shorter labor duration ,potential to reduce healthcare costs

CO-OPERATION REQUIRED:

• Identification of the raw drug from Department of Dravyaguna

• Pathology Lab, AIIA Hospital

• Library, AIIA Hospital

• Pharmacy, AIIA Hospital

• Preparation of medicines from the department of rasa shastra AIIA

•OPD &IPD, AIIA Hospital If needed help will be taken from other departments of AIIA with due permission from concern authority during the course of study.

STUDY ENDPOINTS:

PRIMARY

    1.Improvement in BISHOP score ( > 8)

SECONDARY

    1.Improvement in APGAR Score.

·       Outcomes will be assessed by the BISHOP score and  APGAR Score tables  given in the assessment criteria.

·       Bishop score of 8 or greater is considered to be favorable for induction, or the chance of a vaginal delivery with induction is similar to spontaneous labor.  A score of 6 or less is considered to be unfavorable if an induction is indicated cervical ripening agents may be utilized.The most common modification to the Bishop score is a simplified scoring system that just takes into account dilation, effacement, and station (each scored 0 to 3 points). In this shortened modification, a score of more than 5 is considered favorable.

·       If APGAR score is 0-3 baby will be considered as severely depressed,4-6 as moderately depressed and 7-10 as excellent condition .        

FINANCIAL SUPPORT:

This study will be completed within the prescribed financial limit for the work. However, if more finance is required, the request will be made for due permission and approval of extra budget to the concerned authority AIIA, in due course of research work.

GANTT CHART:

LIST OF REFERENCES

1.Prof.Siddhi  Nandan  Mishra.  Bhaisajya  Ratnavali  by  Kaviraj  Govindnath  Sen  Siddiprada , Hindi  commentary,  Garbhinirogadhikar  68/57.  Reprint  2011.  Varanasi:   Chaukambha Surbharti Prakashan; 2011.p. 1057.

2.Prof.Siddhi  Nandan  Mishra.  Bhaisajya  Ratnavali  by  Kaviraj  Govindnath  Sen  Siddiprada,  Hindi  commentary,  Jwarrogadhikar 5/1268.  Reprint  Varanasi:  Chaukambha Surbharti Prakashan:  2011.P.206.

3.Prof.Siddhi  Nandan  Mishra.  Bhaisajya  Ratnavali  by  Kaviraj  Govindnath  Sen  Siddiprada,  Hindi  commentary,  Garbhinirogadhikar  68/57..  Reprint  2011  Varanasi:   Chaukambha Surbharti Prakashan;  2011;p.1057.

4.D.C  Dutta,  Text  Book  Of  Obstetrics  Including  Perinatology  And  Contraception, Edited By  Hiralal Konar.   7th  Edition.  Reprint  2011.New Central Book  Agency:  Londo; 2011.p.131.

5.Dr.Ravi  Dutta  Tripathi.  Ashtang  sangraha  Saroj,,  Hindi  Commentary  Sutrasthan  1/48 .Reprint  2001.  Varanasi; Chukambha Prakashan,  20.

6.Bhavprakash  Nighantu,  Indian Materia  Medica.  Bhavmishra,  Bharati Acadamy,  Varanasi  ,  10th  edi,  1995

7.Kashinath  Pandey  And  Gorakhnath Chaturvedi . Charak  samhita  Vidyotini vyakhya  Part  –I,.  Shareer  Sthan  6/24, Reprint  2009.  Varanasi:  Chaukambha Bharti Academy:  906.

8.Sushrutsamhita with Ayurveda TatvaSandipika Hindi commentary, KavirajAmbikaDuttaShastri Part-1, Reprint 2008. Chaukhamba Sanskrit SansthanSharirSthan,Garbhinivyakararan sharir adhyaya 10/5

9.Vaidya  Vijay Shankar Kale. Charak  samhita with Vaidyamanorama hindi commentary,Vimansthana rogbhishagjitiya adhyaya 8 ,shloka no 139.

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