Episiotomy is the surgical incision given on the perineum to make available sufficient space for delivery and to reduce severe perineal injuries (Vakili et al., 2018). Its prevalence is 43% to 100% in primiparous women in Asia and it is the commonest obstetrics intervention in the world. Further, worldwide approximately 10-95% of pregnant women undergo episiotomy incision during birth (Mohammadi et al., 2014; Vakili et al., 2018). Instrumental delivery injuries possibly will lead to pelvic floor disorders and there is an increased perineal laceration threat in absence of episiotomy. During vaginal delivery, Asian women are at a higher risk owing to the short perineum body and the kind of tissue to develop severe perineal injuries (Vakili et al., 2018). Delay in wound healing probably increases the risk of wound infection, changes the muscular structure, and ultimately causes muscle tone loss. So, wound care is of specific significance to postnatal maternal outcomes and can expedite women’s return to regular life (Nikpour et al., 2019). In the postpartum period, episiotomy probably causes an increased risk of wound healing problems and a four-fold prevalence of perineal pain in comparison with no episiotomy. Hence, effective pain relief is a foremost feature of postpartum care certainly affecting women’s life (Asgharikhatoon et al., 2015). The conventional treatment for wound healing and pain are ice bags, nonsteroidal anti-inflammatory drugs and analgesics (Vakili et al., 2018). After an episiotomy, the routine procedure for perineal care includes the application of povidone-iodine (Betadine) solution on the perineal wound for healing and antiseptic. Evidence indicates that using CAM is known as a safe treatment among women of reproductive age in industrialized countries and also supports the independence of mothers (Vakili et al., 2018). In the last decade, approximately 20% of the population are using herbal products and it is gaining popularity (Asgharikhatoon et al., 2015).

Unani medicine is the oldest system that prevails to date with its effective remedies. There is a varied systemic and topical treatment to manage perineal injuries (Nikpour et al., 2019). Various compound formulas such as Roghan-i-Hina, Roghan-i-Raal and Marham-i-Hina are useful in wound healing and pain relief. Among these drugs, Marham-e-raal (Anonymous. National Formulary of Unani Medicine, 2006) contains Raal [Vateria indica L.], Kafoor (CinnaMomum. Camphora L.), Kath sufaid [Acacia catechu L.] and Mom [Bee wax]). Marham-i-Raal is useful in the treatment of Jarahat, Quruh-i-Aathishak, Nasur and Quruh-i-Anaf (Anonymous. National Formulary of Unani Medicine, 2006). Raal (Kabiruddin, 2007) and Mom (Beewax) (Khan et al., 2016) has Mudammil-i-Quruh (wound healing), and Muhallil-i-Waram (anti-inflammatory) (Kavitha and Geetha, 2017) properties. Hence useful on the local ulcer and reduces itching and wound scar. Kath is reported to have anti-inflammatory, analgesics, and tissue-protective properties in an experimental model (guinea pigs) (Tangeti et al., 2018). A systematic review has shown the effect of various herbs to improve wound healing and reduce pain (Shahrahmani et al. 2016). Therefore, the objective was to determine the effect of Marham-i-Raal on episiotomy wound healing and pain relief.

This study included eleven postpartum pregnant women admitted to the Maternity Unit, National Institute of Unani Medicine, Bengaluru between 16 February 2020 and 9 April 2021. The inclusion criteria were primi or multipara women aged between 19 and 35 years, singleton with term gestation in a cephalic presentation who had a normal vaginal delivery with mediolateral episiotomy, without a perineal tear, and perineal hematoma. The exclusion criteria were history of reconstructive surgery history of the vagina and the perineum, history of health conditions that could negatively affect wound healing (such as diabetes mellitus, kidney diseases, or severe anaemia), use of medications that could affect wound healing, perineal hematoma and fourth-degree perineal tear.

Details history and clinical examination were collected from the case record form. “REEDA [redness, oedema, ecchymosis, discharge and approximation of the edges] score for wound healing of episiotomy was used. The items of the REEDA scale were scored on a Likert type scale from 0 (“not occurred”) to 3 (“severe problem”)” (Mohammedi et al., 2014; Nikpour et al., 2019). Visual Analogue Scale (VAS) score was used to assess pain intensity. “Pain based ruler from zero to ten cm. Zero represent ‘no pain’, 1-3 Mild pain; 4-6 Moderate pain; and 7-10 consider as severe pain” (Mohammedi et al., 2014). As a routine protocol, for all pregnant women who were admitted for normal delivery, written informed consent was obtained.

Externally, the application of Marham-i-Raal was advised after 2 hours of episiotomy suturing. Patients were taught how to use it and they were advised to use it after washing hands and perineum. Patients were instructed to apply 2 g cream on the perineal wound (stitches) surface, twice a day for 10 days. Pain in the perineal area and the effect of wound healing were evaluated at baseline (1 hour), 12 hours, and on days 7-10. The ingredients of Marham-i-Raal were Ghee (60 g), Raal, Kafoor, Kath sufaid and Mom (each 15g). Marham was prepared in the pharmacy unit of the Institute according to standard Unani parameters as per the classical method described in Unani literature and supplied in our dispensary (Anonymous. National Formulary of Unani Medicine, 2006). Pregnant women received injection ceftriaxone 1 gm in the intrapartum period.

The results were analyzed statistically by using Graph Pad Statistical software. One way ANOVA was applied and p<0.05 was considered significant.

The baseline details of each case are summarized in table 1. The mean age of postpartum women was 24.18±4.70 years. At baseline (one hour), the REEDA mean score of eleven postpartum women was 3.90±1.04 whereas on day 7-10 it was 0.18±0.40 with a statistically significant difference (p<0.001). The VAS mean score at one hour was 6.90±1.22 whereas on day 7-10 it was 0.72±0.78 with a statistically significant difference (p<0.001) [Table 2].

The observation showed that Marham-i-Raal would be effective in episiotomy wound healing and ameliorating pain as it has anti-inflammatory, analgesic and wound healing properties (Khan et al., 2016; Tangeti et al., 2018). Two postpartum mother complained burning sensation after applying the ointment. However, they were explained that because of Kafoor drug, mild burning sensation is felted after applying the ointment. However, other mothers had no complaint or any other side effects

The present study showed statistically significant difference in the REEDA and VAS mean score at post-treatment compared to pre-treatment (p<0.001). Similarly, Asgharikhatooni et al., (2015) observed that Equisetum Arvense ointment reduced REEDA score (0.8±1.3) and efficacious topical formulation in episiotomy wound healing. Lavaf et al., (2017) also reported that honey and phenytoin cream showed episiotomy wound healing and pain relief effect. Mohammadi et al., (2014) in their study reported that C. zeylanicum was effective in episiotomy wound healing with REEDA mean score, 1.6±1.3 and perineal pain relief with VAS mean score, 1.2±1.6 on 10-11 day after delivery. Nikpour et al., (2019) in their study showed that Curcumin and honey creams had similar effects on wound healing and pain relief of episiotomy wound. Vakili et al., (2018) reported that Hypericum perforatum ointment reduced VAS score and effective topical formulation in episiotomy pain relief.

As per the Unani literature, Marham-i-Raal helps in wound healing by aiding in the development of healthy tissue. The same has been proven in the molecular action experiment in albino rats that Marham-i-Raal enhances collagen concentration, epithelialization process and stabilizes the fibres at the wound bed (Ahmad et al., 2019). Raal has Mudammil-i-Quruh, Muhallil-i-Waram, Da’f-i-Ta’affun, and Mujaffi properties (Kabiruddin, 2007) and it is useful on the local ulcer and reduces itching and wound scar. Kath has Musaffi-i-Khun (blood purifier), Mujaffif-i-Zakhm (desiccant of the wound), and Mujaffif (desiccant) properties (Kabiruddin, 2007). It is sprinkled over the wound, itching, and burn ulcer. In syphilitic ulcers, it is used in the form of ointment. It has strong astringent and antiseptic properties. Mom (beeswax) increases the deep penetration of the contents of the Marham-i-Raal (an ointment) in the wound bed. Mom has healing property as it possesses Muhallil-i-Waram, Musakkin-i-Auja’a (analgesic), Mundamil-i-Quruh (wound healing), Munbit-i-Leham (muscle fibre grower), Mujaffif-i-Quruh (Siccative), and Daf-i-Hikka (anti pruritus) activities. It also promotes wound healing and reduces pain in the wound side (Khan et al., 2016). Kafoor has stimulant, rubefacient, demulcent, analgesic and antiseptic activity, when applied locally, it dilates the peripheral blood vessels, is hyperemic and improves the circulation (Chen et al., 2013). Further study has reported that Kafoor de-sensitized the capsaicin receptor (TRPV1) at the same time inhibit the garlic receptor (TRPA1) and act as an analgesic (Chen et al., 2013). It also has skin penetration property. Raal has anti-inflammatory, anti-ulcer, astringent and wound healing activities and it also aids in the wound cleansing activity as it has detergent properties. Ghee has anti-ulcer and antifungal activities (Ahmad et al., 2019). A study has proven Kath (Acacia catechu) has strong incisional wound-healing effect in the animal models (Tangeti et al., 2018). Further, the authors reported that tannins are recognized to enhance the wound- healing process mostly because of their astringent and antimicrobial properties (Li et al., 2011) Furthermore, phytoconstituents such as alkaloids and saponins might play an important role in tissue regeneration in the progression of wound healing (Tangeti et al., 2018). Marham-e-raal contains several phytoconstituents such as linalool, borneol, cineole, terpenoids, Bergenin, phenols, flavonoids, hopeaphenol, oligostilbenoid, monoterpenes, kaempferol, and quercetin. Catechin has been proven for anti-inflammatory, antimicrobial, wound healing, analgesic and antioxidant properties (Ahmad et al., 2019).

Marham-i-Raal would probably be effective in episiotomy wound healing and reducing pain intensity as it possesses Muhallil, Mujaffif and Mundamil properties. Further, randomized controlled trials in large sample sizes are recommended.