In the present study, we investigated the effect of the Verbascum Thapsus cream on the episiotomy section. The results of data analysis of the mean REEDA score showed that Verbascum had a better effect on episiotomy healing compared to the control group, which was significantly higher than the control group on the tenth day of the intervention. In a review of the literature, no similar study was found on the effect of the Verbascum Thapsus cream on episiotomy wounds, and this is the first study to investigate this issue.
The effective and diverse compounds in the Verbascum plant species such as flavonoids, polysaccharides, tannins, saponins, verbacosides, steroids, carbohydrates, and anti-inflammatory and antimicrobial properties are important factors in the regeneration of dermis [20, 25, 31, 32]. As the results of the extraction of the Verbascum chemical compounds in our study showed, one of the most abundant compounds of this plant is the flavonoid, which is consistent with the results of other studies[21, 39]. Flavonoid wound healing mechanisms include increased vascular endothelial growth factor (VEGF), growth factor and hydroxyproline, and anti-inflammatory effects .
In the present study, another compound extracted from the Verbascum Thapsus was phenol. Plant extracts that have high phenolic components, due to their antioxidant, antibacterial, and anti-inflammatory activity, have a high potential for rapid repair of damaged skin tissues; Besides, through stimulating collagen synthesis by fibroblasts, they can help increase wound consistency. In the study of Yadav(2018), the use of phenol-rich topical ointment potentially accelerated the hydroxyproline content and collagen synthesis in the wound . According to the results of these studies, phenol and flavonoid compounds extracted from Verbascum can be effective factors in wound healing. Although no similar study of the effect of the Verbascum on episiotomy wound has been seen in the literature, many medicinal plants have a similar composition to this plant and their effects on episiotomy wound healing have been investigated. One of the plants that have compounds and properties similar to the Verbascum is horsetail or Equisetum arvense . The results of Asgharikhatooni et al.'s study showed that Equisetum arvense ointment caused a significant improvement in episiotomy wounds in nulliparous women . In the study of Shahrahmani et al., The effect of green tea ointment on pain and healing of episiotomy wounds was investigated. In this study, phenol and flavonoids are the extracted compounds of this plant and the comparison of REEDA scores showed healing and acceleration of episiotomy wounds in the intervention group , which is per the present findings.
Due to its anti-inflammatory power and stimulant effects of wound healing, the Verbascum was a promising therapeutic approach in wound healing. In the study of Sohrabi-Haghdost et al.  the effect of the Verbascum Thapsus extract on wounds in rabbits was compared with zinc oxide; The results of histopathological observation of the wound site in the Verbascum group showed young granular tissue rich in fibrin, inflammatory cells, and young epithelial tissue with angiogenesis. Angiogenesis is one of the basic processes of wound healing . The Verbascum has angiogenesis and expression of genes associated with wound healing effects .
In Nebiuni et al.'s study, the effect of the smoke from burning Verbascum leaves on Wistar rat wound healing was investigated and improvement in wound healing of rat was observed in the Verbascum plant group compared to the control group. Factors such as increasing the thickness of the epidermis, angiogenesis to accelerate the process of blood flow to the wound site, along with factor expression (VEGF) have been mentioned as wound healing mechanisms of this plant .
In the proliferative stage of wound healing, due to the migration of myofibroblast cells, the edges of the wound become closer together and the wound size decreases. This process lasts from the second to the fourteenth day of wound healing . The elements in the Verbascum cause the proliferation and migration of fibroblast cells to the wound site . In the present study, better closure and healing of the episiotomy site in the Verbascum group confirms the effect of this plant on wound healing.
Another study in India, entitled The effect of the Verbascum Thapsus on normal and dexamethasone-suppressed wounds in Albino rats, showed that the phytochemical compounds in this plant significantly increase the rate of wound excision closure by increasing the epithelialization process, increasing the volume of granular tissue and the hydroxyproline content . Considering that collagen is the main component of connective tissue scar in wound healing and according to the results of studies that have shown a significant effect of the Verbascum extract in the collagen formation phase, one of the reasons for wound healing can be attributed to this issue.
The Verbascum Thapsus reduces swelling and inflammation of the wound site . It seems that the improvement of redness and secretions at the episiotomy site in this study can be attributed to the anti-inflammatory and antioxidant effects of the compounds of this plant, especially the polysaccharide in it, which accelerates the wound healing process by preventing wound infection[20, 46, 50]. While the results of one study showed that the Verbascum extract oil has no antibacterial and antifungal activity . Other studies support the antibacterial properties of aqueous extract and alcoholic extract of the Verbascum [26, 27, 33]. In the present study, no infection was found at the wound site, which may be due to the antibacterial properties of the Verbascum alcoholic extract.
In the present study, better healing of episiotomy wounds was seen in the Verbascum group compared to the placebo group, and the possible mechanisms and effects of phenol and flavonoid compounds of this plant in the wound healing process were discussed. It is hoped that further clinical trials will provide the necessary evidence for the mass and safe use of this herbal medicine. One of the limitations of this study is the inability to control all factors affecting wound healing, such as differences in the individual immune system; However, in this study, we tried to control the intervening factors to some extent by providing similar training to individuals, random allocation of samples and considering inclusion criteria. Study power includes the assessment of episiotomy wound repair with REEDA scale, control of confounding variables, training and evaluating by the same researcher for each group, episiotomy incision, and suture by a trained midwife and according to standard protocol, using the same suture thread and the same amount of anesthesia for all samples. No dissatisfaction was reported from the samples in the two groups during the study.