Int J Ayu Pharm Chem REVIEW ARTICLE www.ijapc.com e-ISSN 2350-0204

Ayurvedic Concepts of Resuscitation in an Asphyxiated New- Born – A Critical Analysis Rathor Gourav Kumar1* and Shrinidhi Kumar K.2

1,2Department of Kaumarbhritya, National Institute of Ayurveda, Jaipur, Rajasthan,

ABSTRACT Ayurveda the rich medical science which is formulated by keeping the nature as reference, has the credit of protecting the life of Indians since centuries. Meanwhile Ayurveda has given equal importance to child health as evidenced by many references. Certain emergency procedure in childhood practice like new born resuscitation is very essential procedure to save the life of the child. We find explanation of such emergency procedure in Ayurveda too under the heading of Pranaprathyagamana. This includes certain vital steps of resuscitating the baby immediately after birth, by different methods of stimulating the respirations and reviving the baby. Principles behind different steps adapted by Ayurveda in the process of resuscitation nowhere differ from present techniques of contemporary medical sciences and looks like guideline for present advancement in the resuscitation. Analyses of terms like Ashmano sangattana, Krisha Kapalika Shoorpa etc shows similar concepts of sensory stimulation and initiation of breathing by different methods. Certain step adopted are similar to oxygen hood box method, bag and mask ventilation. Further modification of oxygen and aseptic care in Ayurveda has been explained in a comprehensive way.

KEYWORDS Bag and Mask, Krsihna kapalika, Ashmano sangattana

Greentree Group Publishers Received 05/07/18 Accepted 04/08/18 Published 10/09/18 ______

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INTRODUCTION to advanced modern technology, it’s clear Resuscitation of a new born is a vital and that basic principle behind each step hold essential procedure for the successful good even today and looks like guideline 4 revival of the asphyxiated baby. As every for present advancement in resuscitation . delivery should be considered as GENERAL DESCRIPTION emergency importance of the same has Resuscitation is required to all those babies been well understood1. Significant who fail to cry immediately after birth advancement in resuscitation in recent along with failure to initiate spontaneous decades not only reduced the neonatal respiration, floppy baby with absence or morality rate but also successfully revived reduced vitals and hypotonic, i.e. Poor and saved the life in certain critically ill Apgar scoring, irrespective of causes. Such babies2. a state is also called as Asphyxia which has Resuscitation was also very much multi system complication with aberration 5 anticipated procedure even in ancient in blood gas concentrations . Causes for the period, rightly Ayurvedic Samhitas also same may be many like meconium mentioned newborn resuscitation in detail. aspiration syndrome, fatal hypoxia It has been told that during delivery one leg obstructive delivery, bad obstetric history of the pregnant lady is in earth and other in and perinatal events, intra ventricular the Yamalokha which indicates maternal haemorrhages, birth injuries, preterm, post and neonatal mortality rate and risk of term, low birth deliveries etc. In all the sudden emergencies faced during the above told situation the presentation of the delivery3. Rightly to overcome the same, baby at birth is failure initiate breathing procedure by the name Prana with floppiness and with absence of Prathyagamana was mentioned. The word symptoms of life. meaning of Resuscitation is apparently The same situation of no symptoms of life lifting the baby from a death like condition at birth has been mentioned as Achestha while meaning of Prana Prathyagamana is (अचेष्टता) by Acharya Charak and re-establishing the left Prana back in the mentioned different procedures to be body. Ayurveda explains all the essential conducted immediately after birth in case of steps of resuscitation in an order. Although Achesta Shishu6. He says that all procedures certain explanation given in Ayurvedic of resuscitation should be continued till methodology looks outdated in comparison

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baby attains the symptoms of life i.e., till airway before starting the resuscitation, like the baby has been lifted out of Asphyxia. thorough cleaning of the nasal cavity and Word Achestata (अचेष्टता) can be very well oral cavity so as to clear the secretions. correlated with asphyxiated state, with Ayurveda explained the same procedure by APGAR score less than 2 at 1 minute or at using a Kavalika mixed with Saindava 5 minutes. There are no differences in cause (Sodium chloride) and Ghrita, which was of Achestata (अचेष्टता) or Asphyxia. Along wrapped on index finger and cleaning the throat has been done to maximum extent9. with Charaka, other Samhitakars also Same has been also used to induce mentioned different steps, which indicates spontaneous vomiting to clear the amniotic the modification done in Ayurvedic secretions of throat and stomach resuscitation methods from time to time to (Garbhodaka Vamana). put forth best possible practical oriented This is followed by different methods of method for the benefits of asphyxiated stimulating the respiration in order to baby. By arranging all such procedure in an initiate the spontaneous breathing. Delay in order, we can explain the Ayurvedic breathing alters the blood concentration of method of resuscitation i.e. Prana the gases and leading to severe asphyxia Prathyagamana as explained below7. and pH changes. In this scenario the Focus on maintaining the TABC i.e. stimulation of respiration will be tried by Temperature, Airway, Breathing and using the sensory stimulation methods10. It circulations are the main stay of reviving is in routine practice of resuscitation to give the baby and Ayurveda also stresses on the 1-2 firm flicks on the sole of the baby or same. Maintenance of temperature reduces rubbing the chest area or upward pressure is the oxygen demand of baby hence in given in the spinal cord area at lumbar level. Suthikagara where delivery is conducted This helps to stimulate the respiratory has been ensured for temperature regulation centre through the spinal sensory pathways by liting the fire to the stems of different for pain and pressure11. medicinal drugs, lighting the mustard oil Ayurveda explains the same method of lamp, construction of Suthikagara by heat sensory stimulation in more advanced and resistant materials8. which helps to prevent easy way. Ayurveda in the the heat loss by different methods. Bhutaupravesha theory in the process of Further Ayurveda stresses clearing the formation of body. From Atma the Akasha airway for proper ventilation for patency of is formed first, followed by other ______

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Mahabutas12. Hence the human body has startling reflex (Moro’s like response to got more perception for Shabda (शब्द) sound stimulus) for alertness and 15 which is special quality of Akasha response . Contemporary science also Mahabhuta. As it is formed more believes that new born after birth will be primitively body has increased perception always more responsive for sound stimulus for the same. among different kinds of sensory stimulus. On the basis of above principle, Ayurveda When above said first method of tries to stimulate the respiration by sensory stimulating the respiration fails to initiate stimulatory method by using Shabda or breathing the second sensory method of sound stimulus. (अश्मनो: संघट्टन कर्णयोमूल stimulation has been indicated in Ayurveda. In this method second primitively acquired (कर्णवादन)13. To carry on this procedure a special Guna of the body i.e. Sparsha Guna dull sound has been made at the base of the of Vayu mahabhuta is stimulated. Method ear (i.e. mastoid process) by striking small adopted to achieve the same is sudden two stones. This produces a dull sound sprinkling of cold water and hot water which helps to stimulate vestibule cochlear alternatively on the facial region of sick nerve which carries the sound stimulus to baby. (शीतोद्केन उष्णोदकेन मुखे परिषेक) 16. hypothalamus. In further course it also Sensation will be carried through sensory gives a relay branch to the respiratory segment of facial nerve and trigeminal centre. This is true for all sensory fibres nerve to stimulate the respiratory centre. In from the peripheral parts of the body hot season, cold water and in winter season crossing the hypothalamus14. Therefore, hot water can be used. Alternate sprinkling extreme degree of sensory stimulation is of hot and cold water also stimulates always associated with stimulation of sympathetic nervous system, which in turn respiration (As evidenced by suddenly stimulates the respiratory centre. Baby with touching heat and cold followed by apnoea can be easily awakened by this cessation of respiration for a while). method. Sprinkling of cold water to a Purpose of using the stones may be produce person during the state of a dull sound as sharp metallic sounds may unconsciousness/semiconscious is be injurious to labyrinth of the ear, or to generally practiced in community practice, prevent reflux bradycardia, like conditions. which also works on the same principle. Meanwhile this method also helps to check Sudden cooling after birth when a human the response of the baby as in case of

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newborn baby is delivered may lose up to ventilation by using Bag and mask 600kcal/minute at room temperature ventilation has been conducted20. This is an provides respiratory drive by operating artificial method of pushing the oxygen through trigeminal cold receptors located inside lungs helps to overcome the existing on the facial skin17. sudden sprinkling of the positive pressure of the chest. cold water over the facial region (मुखे Although Ayurveda didn’t explain the परिषेक) may serve this purpose procedure of bag and mask ventilation where air is pushed inside the lung Further, Facial area (मुख) is the Adhisthana forcefully, the effort has been done to of maximum Indriyas like Shabda, Rasa, provide high concentration of oxygen to the Ghaana etc. Hence, it easy to stimulate all baby. The same as been explained under the Indriyas by Mukha - Parisheka. Blood heading of Krishna Kaplika Shoorpa circulation is maximum on the facial area (कृष्णकपाललक शुपᴂन अलिलनष्पूर्ीयात)21 The and face is supplied by external carotid . 21% of oxygen present in atmosphere air as arteries which are connected with internal it is usually done in community practice carotid artery containing baro receptors. more than sufficient to carry on positive Role of baro receptors in stimulation of pressure ventilation. Ayurveda explains respiration is well known18. fanning of atmospheric air to the site where Thus, AshmanoSanghatana (अश्मनो baby is placed, and thus providing the high संघट्टन) looks to be the stimulation of concentration of oxygen22. Fanning helps respiration by sensation carrying in through clear impure air and create a negative the vestibulo- cochlear pathway guided by pressure at the site followed by high sound stimulus; while in sprinkling of water concentrated oxygen air to the site. The (शीतोद्केन उष्णोदकेन मुखे परिषेक) causes materials used for fanning are rushing of the stimulation of the trigeminal nerve blackish broken earthen pot pathway19. (कृष्णकपाललक)23. Further to provide high Once the baby is not responding to this two- concentration of oxygen to baby by above methods Ayurveda explain to shift Ayurveda explain the Shoorpa method. for other methods like positive pressure Shoorpa is basket shaped structure which ventilation. As per contemporary methods was covered from all the four sides. This sensory stimulation when fails to initiate method is almost similar to oxygen hood breathing and heart rate fall below hundred box method used to provide high (100) usually the positive pressure ______

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concentration of oxygen to the baby24. air gets moistened and humidified due to Probably exact method of positive pressure SheetaGuna of Kadli Patra (कदली पत्र). It ventilation was not explained in Ayurveda relieves the fatigue and air becomes humid although its basic principle of providing (wet) which brings down Daha (दाह), Pitta high concentration of oxygen was (लपत्त) and induces sleep26. This is similar to explained. Further their efforts were limited conventional practice of converting dry to the use of atmospheric oxygen only, due oxygen in to humidified oxygen passing dry to either lack of knowledge of collecting oxygen through water medium, which is oxygen in a cylinder or due to awareness of comfortable for the body and is devoid of toxic effects of high oxygen (Lenticular the bad effects. Nuclear degeneration as Oxygen is always Pichu Dharana or application of a gauze a double-edged sword. It is true that piece dipped with Bala Taila over the scalp advanced modern methods of resuscitation and the anterior fontanel area or Brahm have saved many lives, but, in prolonged randra pradesha is another step mentioned cases quality of future life of the child is in Prana prathyagaman27. Bala is known always questionable. Such babies carry for its Vatahara property and known for its higher risk of brain- damage resulting in beneficiary effects over the central nervous cerebral palsy, mental retardation, neuro – system. As scalp and head area also muscular pathologies, oxygen toxicity accounts for maximum heat loss, Bala Taila etc25. also works as insulator to prevent the same, Although method of collection of oxygen along with its protective action over was perhaps unknown to them. Method of anterior fontanel which is weak point of the modification of oxygen was well explained. cranium. Further anterior fontanel is un Harihta (हािीत) gives the concept of ossified area, and Ephedrine present in the modification of air for the benefit of sick Bala28 when given with lipid medium like baby. He explains five varieties of fanning Taila can be gets absorbed, however this materials for fanning and idea is to modify needs to be confirmed by researches. the air when it passes through particular Contemporary medical sciences believe in fanning material. Atmospheric air while ice water central cooling to prevent the passing through a particular fanning extensive brain damage in severely material gets modified, like fanning with asphyxiated babies. A similar attempt has Kadali patra (banana leaf) or palm tree leaf,

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been also practiced in Ayurveda in the form blue light instead of white light in of Bala Taila Parisheka29. phototherapy, Open care system of sick However, Ayurveda explains the multi baby instead of incubators etc33. Further the system involvement of Asphyxia due to different steps adopted by different authors various causes in the context of Ulbhka suggest different clinical situation they Roga and while explaining indication of would have been faced. Bala Taila Parisheka 30. Ayurveda also Although certain methods like striking the proposes mantra chikitsa as a last option stones, sprinkling the water to the face which is chanted at the right ear of the baby, looks quite outdated at the present scenario when there is no hope of saving the baby. owing to rapid advancement in neonatal Chanting of the Mantras in rhythmic care special principle behind each step is fashion not only acts as auditory form of quite similar to contemporary medical stimulation but also helps to stimulate the sciences. Rather it gives an impression that electromagnetic waves of the brain as Ayurvedic principles has been reference evidenced in music therapy31. frame for possible present advancement in DISCUSSION. - Ayurveda considered neonatal care. Importance of temperature every delivery as an emergency and chance regulation during resuscitation is quite of high neonatal mortality rate if not obvious and maintained in Suthika gara. handled properly. Considering this fact, Different measures adopted inside the they have adopted all the steps for Suthikaragara help to maintain the higher successful, safe delivery by a procedure degree temperature at higher degree than called Prana prathyagama32. It is obvious that of atmosphere. that, after coming through certain practical Method of sensory stimulation has been difficulties in resuscitation, certain changes dealt in more convincing manner according have been done to formulate a to principles of Ayurveda which is almost comprehensive method of Resuscitation similar to contemporary practice. It is quite which was evidenced by difference of obvious that new born is always highly opinion and change in the order of steps of responsive for sound than any other Prana Parathyagamana adopted by stimulus. Knowledge of sensory different samhitakaras. Such modification stimulation to stimulate the respiratory is quite common in medical field like centre which also highlights their mastery TABC of resuscitation instead of ABC of over anatomy34. resuscitation, utility of soda bicarbonates, ______

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Similarly, the need of high concentration of methodology of resuscitation has also oxygen to an asphyxiated baby and undergone time to time modification as effective way of its delivery to the baby was evidenced by explanation of different well known to them. By analysing the Samhita. Ayurvedic principles of Prana principles behind fanning the baby to prathyagamana which was explained provide the fresh air and by Krishna centuries back looks like base for resent Kapalika and modification of the air to advancement in principles if critical care of provide humidified air by different fanning newborn. materials looks like basic principle of today’s positive pressure ventilation35. Further the Shoorpa or basket like structure to provide higher concentration of oxygen which nowhere differs from oxygen hood box method. Bala Taila parisheka as a method of central cooling in asphyxiated baby was also well explained, and role of Ephedrine (chemical in Bala) to have stimulation of sympathetic nervous system36 and circulation need to further evaluate by researches.

CONCLUSION It is quite obvious that Ayurveda has considered every delivery as an emergency and were prepared to attend the same which is evidenced by the explanation given under Prana prathyagaman. Principles of resuscitation like TABC have been also employed in Prana prathyagamana and will no way differ from the present scenario of neonatal care although methodology adopted is quite different. Ayurvedic

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