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Bovine Cesarean Section in the Field

Article  in  Veterinary Clinics of North America Food Animal Practice · August 2008

DOI: 10.1016/j.cvfa.2008.02.009 · Source: PubMed

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Vet Clin Food Anim 24 (2008) 273–293

Bovine Cesarean Section in the Field

Kenneth D. Newman, DVM, MS
Prescott Animal Hospital, 2725 Edward Street North, Prescott, Ontario, K0E 1T0, Canada

The ideal goals in performing a cesarean section are preservation of the

cow and calf and the future reproductive efficiency of the cow. Both breed
(eg, dairy versus beef) and experience tend to influence the frequency,
ease, and success of this procedure. Dairy practices tend to perform fewer
cesarean sections, but these occur year round. In comparison, cesarean sec-
tions in beef practice are numerous and heavily concentrated during the late
winter and early spring. Furthermore, adverse weather conditions associated
with beef calving practices require appropriate farm facilities for performing
cesarean sections. The ambient environmental temperature in some regions
across North America may not always be conducive to on-farm surgery, es-
pecially in some beef operations. A number of variables determine whether
the procedure is successful. The health status of the cow and calf at the time
of surgery is recognized as the most important determinant of outcome
[1–3]. For this reason, it is worthwhile to categorize a cesarean section as
an elective, emergency (nonemphysematous), or emphysematous procedure.
This article covers the indications, approaches, anesthesia, and surgical
techniques for cesarean section in the field.

Indications
The indications for performing a cesarean section include maternal and
fetal factors [1,2,4]. Maternal indicators include: immature heifers, pelvic de-
formities, failure of cervical dilation, uncorrectable uterine torsion, uterine
tear, hydrops, and prepartum paralysis [4]. Risk factors in cattle are in-
creased by the heifers’ age if less than 2 years old (odds ratio 3.09 compared
with multiparus cows), a long gestation period, a preceding long interval
from first service to conception, a long dry period, a double-muscled [5,6]
(odds ratio 10.85 compared with non-double-muscled breeds) [7] or Pied-
mont sire (odds ratio 4.26 compared with other breed sires), and previous

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 Author's personal copy

274 NEWMAN

cesarean section calving (odds ratio 18.89 compared with those having a pre-
vious normal calving) [7].
Fetal indicators include normal and pathologic fetal conditions [2,4].
Normal fetal conditions consist of absolute fetal oversize (relative to
a normal maternal pelvis size) and malposition. A high value calf, such as
an embryo transfer or clone, may be an indication for an elective cesarean
section. Pathologic fetal conditions include fetal anasarca, schistosomus re-
flexus, hydrocephalus, conjoined twins, emphysematous, mummification,
and prolonged gestation. Depending on the circumstances, including the
availability of a fetotome and the practitioner’s experience, a fetotomy is
not always a viable option. It is inadvisable to attempt a fetotomy if the cer-
vix is dilated incompletely, or when the uterus is either tightly contracted or
friable [4].

Case selection
Case selection tends to be overlooked by clients and veterinarians. When
a cesarean section is considered an option of last resort, a negative outcome
is more likely; therefore, a cesarean section tends to be a self-fulfilling
prophecy [1,3,8,9]. When a cesarean section is chosen early in dystocia cases,
the procedure is more rewarding and clients are more agreeable to future
cesarean sections. Categorizing the procedure as an elective, emergency
(nonemphysematous), or emphysematous procedure is worthwhile, because
the expected outcomes and anticipated complications are dramatically
different for these three situations.
The condition of the cow at the time of surgery is recognized as a major
determinant affecting outcome [1–3,8,10]. Cows undergoing elective cesar-
ean section surgery are less likely to encounter intraoperative and postoper-
ative complications. Cows that have an emergency cesarean section (eg,
malpresentation or uterine torsion) are more likely to encounter intraoper-
ative and postoperative complications (eg, peritonitis) and are less likely to
survive. Rapid clinical assessment (eg, less than 20 minutes) was associated
with improved successful outcomes in two practitioner surveys [9,11] and in
the author’s experience. The ideal emergency case is a cow that has been in
labor briefly, that has a live calf, and the decision to perform a cesarean sec-
tion is made quickly without prolonged obstetric manipulation by either the
client or the attending veterinarian. Excessive manipulations by the owner
and veterinarian without making progress toward successfully delivering
the calf alike were associated with higher postoperative complications. If
the front legs and head cannot be manipulated into the birth canal, the de-
cision to perform a cesarean section should be immediate. Furthermore, to
accommodate larger hips associated in beef breeds, there should be sufficient
room in the pelvic canal for the calf’s head and front legs, with space re-
maining to sweep an arm around the calf’s shoulders to safely extract the
fetus through the birth canal.
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BOVINE CESAREAN SECTION IN THE FIELD 275

Approach
The traditional approaches have been described well in previous litera-
ture [1–4,12,13]. Appropriate restraint (based on the breed), space, light,
available help, location, and the veterinarian’s experience and confidence
[4] are issues that need to be considered in conjunction with the underlying
reason for performing the cesarean, since these can determine the surgical
approach [1,4,12]. The two main options are whether to perform surgery
on a standing or recumbent cow. Depending on the demeanor of the cow,
a recumbent approach using sedation and tying the legs forward and back
may be more appropriate in cases when no chute is present. If the cow
may not remain standing for the duration of the surgery, it may be easier
to start with her in a recumbent position rather than having her fall down
intraoperatively. The recumbent approach facilitates exteriorization of the
uterus, especially when an oversized fetus is present (eg, emphysematous),
thus reducing the opportunity of abdominal cavity contamination [12]
The recumbent approach can be either midline or directly over the pregnant
horn (eg, paramedian or low-flank) [12].
The standing flank approach may be done from either the left or right,
but it is more commonly performed from the left [1,4,11,12]. The primary
advantage of the left approach is that the rumen prevents evisceration of
the small intestines. Rumen prolapse may occur if the cow strains during
surgery, which may prevent manipulation and exteriorization of the uterus.
A caudal epidural anesthesia may reduce abdominal straining. Rumen pro-
lapse also may be reduced by using a stomach tube as a naso-tracheal tube
to inhibit buildup of positive abdominal pressures. In the most extreme
cases (eg, downer cow), the author has performed a rumenotomy to remove
sufficient rumen contents to facilitate completion of the cesarean section
without adversely affecting cow and calf outcome. When the pregnancy is
located in the right horn, some practitioners find it easier to use the right
approach to exteriorize the gravid horn, but retaining the small intestines
within the abdominal cavity potentially may be more difficult.
A left oblique approach in standing cows has been described by Parish
and colleagues [14]. This technique may be useful when removing large
calves or when the uterine contents are contaminated. This incision is larger
and extends more cranial-ventrally compared with the traditional vertical
incision. An incision is started 10 cm cranial and 8–10 cm ventral to the
cranial aspect of the tuber coxae. The incision is extended cranioventral at
a 45 degree angle, ending 3 cm caudal to the last rib. The apex of the uterine
horn is more readily accessible, therefore facilitating manipulation and exte-
riorization of the uterus. The internal abdominal oblique is incised parallel
to the muscle fibers; the abdominal viscera apply tension to this muscle,
which causes apposition during closure.
Some producers have heated facilities when calving assistance or cesarean
sections are required. In an extreme situation (eg, unheated barn and
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276 NEWMAN

ambient temperature well below freezing), a heat lamp placed above the sur-
gical field effectively prevented the muscle layers and the author’s hands
from freezing intraoperatively. Alternatively, some clinics have a haul-in fa-
cility that is heated and equipped with a chute where cesarean sections are
done on an outpatient basis (Fig. 1). Another advantage of a haul-in clinic
is an overhead winch to facilitate calf extraction intraoperatively. Further-
more, the author observed that a smaller skin incision was required and
several cesarean sections could be performed in quick succession with ease
when the winch was used.

Anesthesia and restraint

Sedation may be required in anxious cows. Though xylazine hydrochlo-
ride is the most widely used sedative in bovine practice, it also increases uter-
ine tone, thus making manipulation and exteriorization of the gravid uterus
more difficult [1,15,16]. Since xylazine alters laryngeal and pharyngeal anat-
omy and impairs sensation in adult dairy cattle [17], there is increased risk of
aspiration pneumonia developing postoperatively if the sedated cow is posi-
tioned in either lateral or dorsal recumbency. Furthermore, xylazine also
may induce ataxia, an undesirable effect when performing a standing cesar-
ean section.

Fig. 1. Chute system with removable side bars and adjustable headgate for haul-in facility.
Note location of overhead hand-operated winch at the rear left corner of the chute. After incis-
ing the uterus and placing sterile calving chains on the calf’s legs, the client then operates the
winch to facilitate calf delivery. To improve safety and comfort during surgery, a rubberized
matt is placed on the floor adjacent to chute. (Courtesy of Rodney Webber, DVM, Rosthern,
SK, Canada.)
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BOVINE CESAREAN SECTION IN THE FIELD 277

In most dairy operations, restraint is provided primarily by a halter and

a ‘‘tail jack’’ administered by the producer. The availability of a chute in
beef operations is variable. Quiet, well-mannered beef cows may be re-
strained adequately similar to most dairy cattle; however, there can be no
substitute for a sturdy chute when dealing with less cooperative beef
cows. When a halter is the sole means of restraint in dairy heifers, the author
has found that the combination of 7.5 mg acepromazine maleate and 10 mg
of butorphanol tartrate administered intravenously provided adequate seda-
tion (unless the heifer was already in a highly excitable state) for standing
surgery without causing either ataxia or increased uterine tone.
A combination of ketamine hydrochloride (0.04 mg/kg intramuscularly
[IM]), butorphanol tartrate (0.01 mg/kg IM), and xylazine hydrochloride
(0.02 mg/kg IM) may provide satisfactory standing chemical restraint for
1 hour in highly anxious cows; the author has used this combination for
other procedures on the farm and anticipates this also may be useful
for standing cesarean sections. A more potent combination of ketamine
hydrochloride (0.1 mg/kg IM), butorphanol tartrate (0.025 mg/kg IM)
and xylazine hydrochloride (0.05 mg/kg IM) provides satisfactory recum-
bent chemical restraint for 30 minutes without inducing general anesthesia.
The author has used this combination for herniorrhaphy, claw amputation,
and cast changes on the farm and also anticipates this would provide ade-
quate sedation for recumbent cesarean section. Additional administration
of drugs may be required in certain situations to extend sedation. For
more details of these and other useful combinations for effective chemical
restraint, please see the article written by Abrahamsen elsewhere in this
issue.
Surgical approach determines which local anesthesia technique is used.
Techniques for local anesthesia are well documented in other literature
[1–3,18–21]. The most common techniques are the proximal paravertebral
and distal paravertebral, inverted ‘‘L’’ block, and line blocks. The technique
used reflects the surgeon’s preference; the author finds it more efficient to ad-
minister the distal paravertebral in less conditioned (eg, dairy) cows and the
proximal paravertebral in more conditioned (eg, beef) cows. Though the
proximal paravertebral block is more challenging technically and requires
more restraint and a long needle (minimum 20 gauge 10 cm long), this block
uses the smallest dose of local anesthetic, provides the maximum anesthetic
region, and induces maximum relaxation of flank musculature. When facil-
ities are marginal (no chute) and a tail jack is insufficient in preventing the
cow from kicking, it is possible to administer a proximal paravertebral block
when standing on the opposite side by reaching over the lumbar area. The
distal block requires less skill and restraint and may be performed using
an 18 gauge 1.5 inch needle. This block works well, provided the local anes-
thetic injections are fanned above and below the edge of the transverse pro-
cesses. The line block is the least technically challenging, but it requires the
greatest amount of local anesthetic [18–20]. Though epinephrine reportedly
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278 NEWMAN

increases the duration and decreases the toxicity of local anesthesia by caus-
ing vasoconstriction, incisional complications, such as delayed healing and
skin slough, have been associated with the used of lidocaine with epineph-
rine for line blocks [21].
Regardless of which local anesthetic block is administered, the effective-
ness of the block always should be tested before commencing surgery. On
rare occasions, the author has had a cow respond irregularly when flank an-
esthesia is testeddthe cow seemingly kicks randomly at the surgeon without
painful stimuli. However, consistent flank anesthesia is demonstrated when
the cow’s line of vision is blocked (eg, have the client stand by the cow’s
shoulder). An efficient solution is to place either an empty feed bag or
a vest or jacket over the cow’s eyes and hold it in place with a halter to
reduce the cow’s visual cues for the duration of the surgery.
A caudal epidural anesthesia [18–21] using 2% lidocaine hydrochloride,
which desensitizes the caudal nerve roots as they emerge from the dura, of-
ten is indicated if either the calf or obstetric manipulations have initiated
strong abdominal contractions (Ferguson’s reflex) and should not affect
hind limb motor control provided that an excessive volume is not ad-
ministered. A xylazine caudal epidural has been described in other literature
[21–24]. Xylazine, (0.05–0.07 mg/kg) is diluted with 0.09% sodium chloride
to provide a final volume of 5 to 7.5 mL. Cows became mildly ataxic (but
remained standing) in 80% of the cases. Xylazine epidural has a delayed on-
set of approximately 30 minutes, and additional local anesthetic was re-
quired in 15% to 20% of the cows [24]. Therefore, this technique may not
be the most efficient in field situations. This technique can be used in con-
junction with local techniques to enhance sedation and analgesia in less co-
operative patients. A portion of the 0.9% sodium chloride volume can be
substituted with 2% lidocaine for a more complete caudal epidural anesthe-
sia [20]. Alternatively, an anterior epidural anesthesia can provide flank an-
esthesia [19,21], but it is likely the most technically challenging epidural to
administer [21]. Unlike the caudal epidural, the anterior epidural affects
hind limb motor control [19,21]. If an epidural is not administered, the
tail always must be tied to the cow’s leg to prevent intraoperative contam-
ination. After the administration of an epidural, the tail jack will no longer
be effective in providing additional restraint if it is required.

Patient preparation
Details of patient preparation have been reported previously in other lit-
erature [25,26]. Hair removal by clipping alone has been reported to incite
fewer skin reactions with no significant difference in incisional infections
compared with clipping and shaving [27]. To facilitate patient preparation
expeditiously on the farm, the author typically administers either a distal
or paravertebral local anesthesia block before clipping. The area clipped
should extend 20 cm to 30 cm on either side of the intended incision [25].
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BOVINE CESAREAN SECTION IN THE FIELD 279

Because the author tends not to use a drape for standing cesarean sections in
the field, clipping and cleaning a larger area (especially ventral to the in-
tended incision) likely prevents contamination (Fig. 2). Cows with heavy
hair coats (eg, beef cows) can be clipped efficiently in mere minutes by using
a large pair of clippers (Oster Clipmaster Clipper, Sunbean Products Inc.,
Boca Raton, Florida) and a standard blade. The intended incision site is
clipped using a #40 blade (Oster Golden A5, Sunbean Products Inc., Boca
Raton, Florida) The author typically uses a chlorhexidine gluconate scrub
until the skin surface appears sufficiently clean, which is followed by iso-
propyl alcohol and povidone-iodine solutions. There were significant fewer
colony forming units and negative cultures after washing with chlorhexidine
gluconate compared with povidone-iodine [28]. Chlorhexidine gluconate is
less likely to mask the degree of cleanliness, because its use requires observ-
ing when the skin surface is sufficient clean compared with povidone-iodine.

Surgeon preparation
Details of surgeon preparation have been reported in previous literature
[25,26]. The surgery pack should be set up in a safe location adjacent to
the surgeondan impromptu surgery table may be made from one or
two square bales set up behind the surgeon. An impervious gown is recom-
mended [29]. The author prefers to wear a rubberized two piece obstetric
suit (OB suit J-30SR, Jorgensen Laboratories Inc., Loveland, Colorado)
for comfort, especially in cooler climates to stay dry and warm. If condi-
tions are warm, the top may be removed easily and new latex gloves
donned after the calf is removed and the uterine incision suture is closed.
Because of the environmental conditions present during bovine field sur-
gery, a cap and mask are not required; however, sterile latex surgery
gloves and plastic sleeves are highly recommended [25]. When plastic

Fig. 2. Recommended area to clip during patient preparation for either left paralumbar or ob-
lique approaches for cesarean section. (Courtesy of Matt D. Miesner, DVM, MS, Manhattan, KS.)
 Author's personal copy

280 NEWMAN

sleeves are worn with latex gloves, the tips of the plastic sleeves may be cut
off to improve tactile sensation [25]. Sterile calving chains also are recom-
mended to facilitate calf removal. A minimum of one physically capable
assistant is required. An ideal time to instruct the assistant on when and
how to assist during surgery is when the surgeon is preparing; occasionally
reminders are required intraoperatively if the assistant appears overly anx-
ious to lend assistance.

Surgical technique
Details of the surgical techniques for performing a cesarean section are
well described in other literature [1–4,18]. The abdominal wall incision
should be large enough to safely remove the fetus. A small abdominal in-
cision tends to increase the level of difficulty in removing the fetus and
increases the risk of subcutaneous emphysema and seroma formation. Af-
ter identifying the uterus, the portion of the uterus containing a hind leg
is pulled up into the abdominal incision by grabbing the calf’s metatarsal.
Placing one hand under the hock and the other on the dorsal aspect of
the pastern facilitates ‘‘locking’’ the foot into the abdominal incision
(Figs. 3 and 4). With breech or posterior presentations, the front limb
is grasped. This increases the level of difficulty exteriorizing the uterus
and may require a larger incision. The greater curvature of the uterus
should be exteriorized, and using a second scalpel blade, an incision
should be made along the greater curvature of the uterus, avoiding major
blood vessels and caruncles. Beginning the incision at the hock and ex-
tending the incision distally toward the foot will prevent the uterus
from sliding down around the calf’s leg. In the event that the gravid
horn is located opposite the paralumbar incision, the uterus can be

Fig. 3. By grasping the hock and fetlock, the uterus may be manipulated up to the incision and
exteriorized. (Courtesy of Matt D. Miesner, DVM, MS, Manhattan, KS.)
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BOVINE CESAREAN SECTION IN THE FIELD 281

Fig. 4. The uterus locked into the incision. (Courtesy of Matt D. Miesner, DVM, MS, Manhat-
tan, KS.)

manipulated and exteriorized. First, reach with both arms under the
gravid uterus and lock the hands around the dorsal aspect of the gravid
uterine horn. Second, pull down and toward the surgeon with both hands
to complete the rotation. However, suturing the uterine incision closed af-
ter fetal extraction will be more challenging, because the torsed uterus
tends to self correct.
A small uterine incision increases the risk of tearing the uterus, which typ-
ically occurs at oblique angles to the uterine incision and increases the level
of the difficulty in uterine closure. Uterus tearing during surgery accounted
for 6.8% of complications [30], which is comparable to the experience of the
author. No difference was observed in cow survival with uterine tears and
whether the calf was alive or dead (except for emphysematous fetus) at
the time of surgery. Unfortunately, the impact of uterine tears on adhesion
formation and reproductive efficiency is not known.
Under ideal circumstances, spillage of uterine contents into the abdomen
should be avoided. Once both legs are exteriorized (and sometimes the
head if dealing with an anterior presentation), calving chains can be placed
on the calf’s legs to facilitate fetal extraction. While the calf is being re-
moved, the uterus needs to be held in place to prevent spillage of uterine
contents into the abdomen. This process can be facilitated by using bovine
uterine grasping forceps. Also, the umbilical cord should be stretched and
ruptured in a controlled fashion by holding it adjacent to the abdominal
wall. Normal retraction and contraction of the umbilical arteries may be
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282 NEWMAN

impaired by surgical excision of the umbilical cord. If an elective cesarean

section is performed, careful attention is paid to the umbilical vessels, be-
cause they are not prepared for spontaneous rupture and are more suscep-
tible to excessive hemorrhage. Temporary clamping of the umbilical
arteries and vein may be required; however, the author has observed an
increased incidence in umbilical infections when these vessels are ligated us-
ing suture material. After the calf is removed, always check for a second
calf. The author’s preferred technique is to use an arm in a sweeping
motion around the uterus to maximize uterine exteriorization and facilitate
suturing the uterus incision. If the placenta readily detaches from the car-
uncles it should be removed; otherwise, trim the portion that is hanging
outside the uterus.
If the calf is alive and the uterus is healthy (eg, an elective procedure), one
layer of closure with absorbable suture material (eg, 3 chromic catgut) using
a taper needle is sufficient. Two layer closure is recommended if the calf is
dead, if suspected contaminated uterine fluids are present (eg, an emergency
or emphysematous procedure), or if the uterine wall is compromised or torn
during fetal extraction. Closing the uterus can be easier with an assistant
holding the uterine horn dorsal to the uterine incision and permitting the
uterus to hang down vertically; the two sides of the uterine incision are
more closely opposed, which facilitates suturing. Continuous inverting su-
ture patterns (eg, Cushing, Utrecht, or Lembert) that do not take full thick-
ness bites should be used, because they provide a tight seal, minimize suture
exposure, and promote healing, because the uterus heals initially by serosal-
to-serosal contact. The author prefers to use either the Cushing or Utrecht
suture, because the Lembert pattern requires more suture material, has more
suture material exposed, and takes more time to complete. Suture exposure
(especially at the knots), rather than the type of suture material, is thought
to be the most significant cause of adhesions along the uterine incision.
In the field, #3 or #4 chromic catgut (Chromicgut, Ethicon, Johnson &
Johnson, Somerville, New Jersey) historically is the most used suture mate-
rial in bovine surgery, because of availability, cost, and packaging
convenience [25]. Catgut is derived from either the sub-mucosa of sheep
intestine or serosa of bovine intestine and is braided and easy to handle,
though it has poor knot security. Plain catgut loses its tensile strength
very rapidly, whereas chromic catgut loses 50% of its tensile strength after
7 days. Breakdown is accelerated in the presence of infection. Because of
concerns regarding bovine spongiform encephalopathy, the use of catgut
in certain afflicted countries is prohibited [31]. Despite having the highest
initial tensile strength compared with other suture materials, polyglecaprone
25 (Monocryl, Ethicon, Johnson & Johnson, Somerville, New Jersey) also
has very rapid loss of tensile strength and should be used only for uterine
closure and not for closure of either muscle or linea alba. Polyglactin 910
(Vicryl, Ethicon, Johnson & Johnson, Somerville, New Jersey), polydioxa-
none (PDS, Ethicon, Johnson & Johnson, Somerville, New Jersey), and
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BOVINE CESAREAN SECTION IN THE FIELD 283

polyglyconate (Maxon, Ethicon, Johnson & Johnson, Somerville, New Jer-

sey) would be appropriate suture materials for closure of the uterus, muscle,
and linea alba. Synthetic materials have significant advantages over biolog-
ical material. Polyglactin 910 has the advantages of uniform material qual-
ity, is less readily damaged by surgical instruments, has superior handling
qualities (ie, is less stiff, is better for knot tying, and has less fraying), and
causes a mild inflammatory reaction compared with plain catgut. It is un-
known whether polyglactin 910 induces less scar formation within the myo-
metrium, which could positively affect future fertility. The disadvantages of
polyglactin 910 are increased drag (because it is braided) and cost. Of these
materials, the author prefers to use polyglactin 910, because it is easy to han-
dle; however, caution must be exercised because of poor knot security.
Though polyglactin 910 is braided and more susceptible to the wicking of
bacteria because of capillary action, this suture material remains stable in
an infected environment.
Blood clots should be teased gently away using irrigation and a gloved
hand, because these clots may give rise to adhesions that can adversely af-
fect future fertility. Gauze sponges should not be used to wipe the uterus
clean, because this causes serosal abrasions, which increases the likelihood
of detrimental uterine adhesions. The ovarian bursa should be examined,
because blood clots can lodge there, cause adhesions, and adversely affect
future fertility. Isotonic fluids, such as sterile physiological saline or bal-
anced electrolyte solutions, may be used to rinse off the uterus. After rins-
ing, the uterus is replaced inside the abdomen. A combination of heparin
(40 U/kg) and either potassium penicillin (22,000 U/kg), ceftiofur hydro-
chloride (1 mg/kg), or oxytetracycline hydrochloride (200 mg/kg) mixed
in with 500 mL of 0.9% sodium chloride irrigation solution that is instilled
in the abdomen for abdominal lavage is used empirically (depending on the
surgeon) as an aid to reduce adhesion formation. Changing to new surgical
gloves once the uterus is closed potentially reduces the risk of abdominal
contamination.
The abdominal wall usually requires two to three layers of closure. The
peritoneum and transversus usually are closed in one layer, using absorbable
suture material (eg, 3 chromic catgut) in a simple continuous pattern. The
internal and external oblique muscles are closed together using absorbable
suture material (eg, 3 chromic catgut) in a simple continuous pattern. To re-
duce dead space and potential seroma formation, the layers can be tacked
down periodically to the preceding layer. Reducing dead space also may in-
hibit seroma formation and incisional infections [25]. The skin can be closed
using nonabsorbable suture material (eg, 3 polyamide) in a continuous ford
interlocking, simple interrupted cruciate, or simple interrupted suture pat-
terns (Fig. 5) If the ford interlocking pattern is used, the current recommen-
dation is to place several simple interrupted sutures at the base of the
incision (Fig. 6). These sutures could be removed to facilitate drainage in
the event of an incisional infection.
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284 NEWMAN

Fig. 5. Ford interlocking suture for skin closure. Note use of large serpentine needle to expedite
suturing process. (Courtesy of Matt D. Miesner, DVM, MS, Manhattan, KS.)

Fig. 6. Photograph of completed ford interlocking suture for skin closure after left oblique
approach for cesarean section. (Courtesy of Matt D. Miesner, DVM, MS, Manhattan, KS.)
 Author's personal copy

BOVINE CESAREAN SECTION IN THE FIELD 285

Uncorrected uterine torsion presents an interesting dilemma for the vet-

erinary surgeon; does one remove the calf before or after correcting the
torsion intraoperatively? Uterine torsions in the bovine typically are ro-
tated counterclockwise (63%) when viewed from behind the cow, with
the right gravid horn rotated over the left horn [32]. Since the left paral-
umbar fossa is likely, by default, the most common approach, the gravid
right horn will be adjacent to the body wall incision, which facilitates ex-
teriorization of the uterus. However, removing the calf first tends to make
suturing the uterine incision more difficult without surgical assistants. Al-
ternatively, correcting the torsion before calf removal places the gravid
right horn opposite from the left body wall incision, which makes it
difficult to exteriorize the uterus. Selecting the approach based on the
direction of the torsion may be the ideal solution. For example, a counter-
clockwise torsion could be approached from the right paralumbar fossa,
the torsion first corrected intraoperatively, then the uterus exteriorized,
the calf removed, and the uterus incision sutured closed.

Postoperative care
The use, type, and frequency of antibiotics vary on a case-by-case basis.
Unlike procedures done in a controlled hospital environment, cesarean
sections performed on the farm are routinely administered antibiotics.
The most commonly used antibiotics are either penicillin G procaine
(22,000 U/kg IM quaque (q) 24 hr for 3–5 days), oxytetracycline (6.6–11
mg/kg intravenously, IM, or subcutaneously (SQ) q 24 hr for 3–5 days),
or ceftiofur hydrochloride or ceftiofur sodium (1.1–2.2 mg/kg intravenously,
IM, or SQ q12–24 hours for 3–5 days). Specifically in beef cattle, florfenicol
(20 mg/kg IM q 48 hours or 40 mg/kg SQ q96 hours) also can be used. In
both Canada and the United States, aminoglycosides should not be used
in food producing animals. Client compliance may improve when using ei-
ther oxytetracycline or florfenicol, because these antibiotics do not require
daily administration. Under ideal circumstances, high antibiotic tissue con-
centrations should be present at the time of surgery [33]. Therefore, ideally
antibiotics should be administered before surgery. When the preoperative
and intraoperative complications are marginal (eg, the calf is alive, the
cow has a healthy uterus, and there is minimal abdominal cavity contamina-
tion), the author uses penicillin G procaine (IM) in dairy and oxytetracy-
cline (preferably SQ) in beef cows. When complications are severe (eg,
there is an emphysematous calf, a compromised uterus, or severe abdominal
contamination) and the risk of peritonitis is high, the extralabel use of oxy-
tetracycline (20 mg/kg IV q 24 hours) administered daily for 5–7 days (max-
imum) was beneficial based on the author’s experience. Treatment beyond 7
days tended to inhibit the rumen microflora and motility. In some circum-
stances, placing a 14 gauge 5.25 inch intravenous catheter and training
the client to administer the oxytetracycline dose intravenously (added to
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286 NEWMAN

a bottle of physiologic saline or dextrose) can facilitate daily treatments.

Furthermore, a heparin-saline flush can be made quickly using a green
top blood collection tube. When antibiotics are used, the appropriate milk
and meat withdrawals need to be followed. If required, extra label use of an-
tibiotics should be done cautiously and with close attention to prevent res-
idue violations.
For postoperative analgesia, a non-steroidal anti-inflammatory medica-
tion, such as either flunixin meglumine (2.2 mg/kg intravenously q12 hours
for 2–3 days) or ketoprofen (3 mg/kg intravenously, IM q 24 hours for
2–3 days) would be appropriate choices. Flunixin meglumine also may be use-
ful in preventing abdominal adhesion formation. Flunixen meglumine is li-
censed for intravenous use in lactating dairy cows in Canada and the United
States. Currently, ketoprofen is approved for use in lactating dairy cattle in
Canada but not in the United States, but it could be employed under the An-
imal Medicinal Drug Use and Clarification Act of 1994 or it may be approved
in the future. When nonsteroidal anti-inflammatory medications are used, the
appropriate milk and meat withdrawals need to be followed. If required, extra
label use of nonsteroidal anti-inflammatories should be done cautiously and
with close attention to prevent residue violations.

Complications
An extensive list of preoperative, operative, postoperative, and long term
complications have been reported [10]. Preoperative complications included:
delayed delivery, anorexia, fetal death, emphysematous fetus, forced extrac-
tion, fetal abnormalities, fetal limb fractures, uterine inertia, uterine trauma,
uterine rupture, obturator/sciatic nerve cowage, and severe trauma during
manipulation. Operative complications included: excessive uterine trauma,
peritoneal cavity contamination, gastrointestinal trauma, and excessive trauma
to abdominal wall and inadequate uterine closure. Postoperative complications
included: peritonitis, seroma formation, retained placenta, metritis, endometri-
tis, skin suture dehiscence, subcutaneous emphysema, adhesions, mastitis,
straining, and cow or calf death. Long term complications included: downer
cow, debilitated cows, production losses, increased calving-service intervals,
increased services per conception, spontaneous abortions, and infertility.

Exteriorizing the uterus

A bovine cesarean section is considered a clean-contaminated procedure.
Exteriorizing the uterus and avoiding abdominal contamination is most im-
portant when dealing with a dead calf or after extensive obstetric manipula-
tions. The most common intraoperative complication observed in a study of
1,000 cesarean sections was exteriorizing of the uterus (20.8% difficult, 5.8%
impossible) [30]. More experienced surgeons appeared to have less difficulty
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BOVINE CESAREAN SECTION IN THE FIELD 287

in exteriorizing the uterus. Based on the author’s experience, cows were

more likely to survive when the uterus was exteriorized during the surgery;
when the uterus was not exteriorized, improved survival was noted in cows
that had a live fetus. Furthermore, improved survival was observed in cows
where the uterus was exteriorized to remove a dead fetus compared with
when the uterus was not exteriorized.
When the uterus has contracted tightly on the fetus, it is more difficult to
either correct malpresentation or to exteriorize the uterus during a cesarean
section. Clenbuterol and isoxsuprine have been available to bovine practi-
tioners as aids in obstetric manipulation [34,35]. However, these drugs pres-
ently are not permitted for use in food producing animals in North America.
In recent experiments using B2-adrengeric receptor agonists, ritodrine and
terbutaline effectively relaxed the myometrium in dairy [36] and beef cows
[37], respectively. Further research is required before these tocolytic agents
are used in clinical cases. Isoxsuprine has sympathomimetic properties
with structural similarities to epinephrine [34]. Therefore, epinephrine may
have inherent tocolytic pharmacologic properties. An empiric dose of
10 mL of 1:1000 epinephrine that is diluted using a small volume of isotonic
fluid and administered intravenously 10 minutes preoperatively appears to
relax the uterus, thus facilitating exteriorization of the uterus. Administering
epinephrine to selected cows with dystocia (eg, malposture or breech presen-
tations) has sufficiently relaxed the myometrium in most instances to facili-
tate obstetric manipulations and successful vaginal delivery of the calf in the
author’s experience. On a few occasions, the author observed transient ex-
aggerated respiratory excursions and generalized hyperhidrosis in cows in
which epinephrine was administered perioperatively, which was likely the re-
sult of rapid administration, and the cows returned to normal by the end of
surgery. The author noticed that the uterine wall tends to thin, because the
myometrium relaxes, which makes closing the uterine incision more chal-
lenging. A small tapered needle is required to avoid full thickness bites,
and the sutures need to be placed more closely together to ensure proper clo-
sure of the uterus.

Retained fetal membranes

The bovine placenta typically is shed within 24 hours after surgery [9].
Failure to shed the placenta within this time is considered a retained fetal
membrane. The placenta was removed easily during surgery 6% of the
time, and 59% of cows shed the placenta within 12 hours of calving [8].
The occurrence of retained fetal membranes was between 35% and 40.8%
[8,38], which are generally accepted as being higher compared with unas-
sisted calvings. In cases when the placenta was not removed during surgery,
oxytocin (20 United States Pharmacopeia (USP) q 3 hr IM) may be admin-
istered on days 2 and 3 post-calving, then increasing both the dose and fre-
quency of oxytocin to 30 USP q 2 hr on day 4 [39]. Smaller doses
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288 NEWMAN

administered more frequently are recommended, rather than high doses less
frequency. Smaller doses induce productive uterine contractions in a tubulo-
cervical manner, whereas high doses appear to cause tetanic-like spasms,
which can last between 6 and 10 minutes [39].

Recumbency
A rate of 14.8% of cows becoming recumbent intraoperatively has been
reported in other literature [30]. It is believed that cows are more likely to
become recumbent during attempts to exteriorize the uterus, because of
the pain that arises from traction on the broad ligament during difficult uter-
ine manipulations. Administration of xylazine epidural preoperatively or
butorphanol tartrate intraoperatively may reduce painful stimuli. Cows
that remain standing during the procedure have a better chance of survival,
with reports of 91%–94% cow survival rate and a 95%–100% calf survival
rate [8]. In the author’s experience, cows that fall down intraoperatively
were more likely to develop peritonitis and experienced greater postopera-
tive mortality compared with cows that remained standing during the
surgery.

Mortality
A retrospective study that looked at 159 dairy cow cesarean sections found
a strong correlation between cow survival and calf viability at the time of sur-
gery [38]. Cow survival decreased from 86% with a live calf, to 79% with
a dead calf, to 33% with an emphysematous fetus. Surgery time greater
than 1 hour reduced the cow survival rate from 96% to 86% [9]. The most
common complications associated with maternal death are peritonitis, toxe-
mia, metritis, uterine rupture, and fatty liver [10]. It is generally accepted
that beef cows tolerate surgery better and have improved outcomes, because
they usually have a heavier body condition and significantly lower metabolic
demands compared with dairy cows. Infection by Clostridium chauvoei dis-
tant to the surgery site is reportedly rare (0.5%) and has been associated
with sudden death of the cow within 24 hours of surgery [10].
Recently, a study demonstrated the toxicity arising from abdominal con-
tamination with a polyethelene polymer (PEP) based obstetric lubricant ap-
proved for use in cows [40]. Though this lubricant has been used safely and
effectively for obstetric lubrication, peritoneal contamination with as little as
1.25 g of PEP (equivalent to 1.0 L of a 0.5% weight per volume (w/v) solu-
tion) is toxic to cows, but the mechanism is unknown. The cows either died
or developed sufficiently severe clinical signs to warrant humane euthanasia
within 3–6.5 hours post-PEP intra-abdominal infusion. Because PEP was
used frequently during severe dystocias, there was increased risk of abdom-
inal contamination with PEP interoperatively if the uterine contents were
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BOVINE CESAREAN SECTION IN THE FIELD 289

spilled. In hindsight, this toxicity may explain, in part, the sudden cow
deaths within 24 hours after cesarean section observed in anecdotal reports
and by the author.

Peritonitis
The apparent incidence of peritonitis is relatively low at 10.5% [30]. The
clinical signs of peritonitis are expected to occur 3–4 days after surgery
[1,4,15]. In a practitioner survey, peritonitis was considered the leading cause
of death (70.3 %), followed by shock (18.1%) [11]. Peritonitis may be caused
by compromise of the uterine wall even before surgery [10]. Peritonitis can be
caused by either exogenous (through the abdominal incision) or endogenous
bacterial flora [41]. Fetal fluids can become contaminated by obligate, anaer-
obic vaginal bacterial flora, especially after either rupture of the amniotic sac
or extensive obstetric manipulations. Bacteria can be cultured from uterine
fluids before amniotic sac rupture; however, their numbers increased signifi-
cantly after the sac was ruptured. During cesarean section, the uterine fluids
were heavily contaminated 83% of the time by a polymicrobial population.
Since prolonged obstetric manipulations appear to increase the risk of perito-
nitis, they validate the observations that rapid clinical assessment when decid-
ing to perform a cesarean section is associated with successful outcomes.

Incisional complications
The disadvantages of the recumbent approaches include increased surgi-
cal time, increased risks of intraoperative hemorrhage, postoperative seroma
formation, and incisional herniation. The thin facial layers associated with
the lateral approaches are more likely to herniate. The linea alba provides
a stronger holding layer compared with either the paramedian or low obli-
que approaches; furthermore, there are fewer layers of closure compared
with the paramedian and low oblique approaches, which would reduce
surgery time.
Complications associated with paralumbar incisional infections are
between 1.3% [9] and 8.2% [8] and dehiscence 3.8% [9]. The occurrence
of subcutaneous emphysema has been reported between 0% and 41%
[8,9,15]. Differences in surgical site preparation, local anesthetic technique,
incision length, difficulty removing the calf through the incision, time of
surgery, and the use, type, and duration of postoperative antibiotics make
it difficult to make clear inferences from these reports. Subcutaneous emphy-
sema could be reduced by closing the peritoneum along with the transversus,
thus sealing the abdomen. Applying pressure to the opposite abdominal wall
to expel intraabdominal air during closure of the first layer also has been
suggested as a means to reduce subcutaneous emphysema [10].
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290 NEWMAN

Adhesions
The prerequisites for adhesion formation are tissue trauma, bacteria, and
inflammation; therefore, medical treatment for adhesion prevention includes
good surgical technique, antibiotics, and nonsteroidal anti-inflammatory
medication. An imbalance between fibrin formation and fibrinolysis is be-
lieved to result in adhesion formation. Adhesions can be clinically irrelevant,
beneficial, or detrimental, and their significance is determined by their loca-
tion and degree. Detrimental adhesions in the bovine abdomen following
cesarean section are primarily associated with elements of the reproductive
tract; the ovary, infundibulum, oviduct, and uterus in decreasing order are
the most critical elements with respect to future fertility. Pre-existing uterine
adhesions were found in 9.4% [30] of the cows compared with 20%–60%
[30,41] of the cows that had a previous cesarean section. Halsted’s principles
of surgery are the mainstay of adhesion prevention [42,43]. In one study,
a significant difference was observed between surgeons and adhesion forma-
tion [41].

Fertility
Cesarean section in dairy cattle did not change the interval to first service
or subsequent gestation length [44]. Cows that had a cesarean section had an
increase in services per conception and days open [4,8,10]. The calving to
conception interval was 110 days (give or take 43 days) in dairy cattle and
99 days (give or take18 days) in beef cattle. No difference in the rate of abor-
tion between cesarean section and normal deliveries was observed [44]. The
pregnancy rates in dairy and beef cows after having cesarean sections are
72% and 91%, respectively [8]. These rates appear reasonable for routine
cases. The lower pregnancy rates in the dairy cattle could be attributed to
confounding variables, such as culling for non-reproductive reasons (eg,
lameness). In beef cows, a negative correlation was observed between fertil-
ity and the level of calving assistance required, especially when a cesarean
section was performed; [45] however, the effect of body condition was not
considered and may have been a confounding variable.

Production
The effect of a cesarean section on milk production is difficult to elucidate
because of numerous confounding variables. When the effects of herd, year,
parity, calving season, and abortion were corrected, cows that had a cesarean
were less likely to reach 100 days in milk (DIM), and produced, on average,
79.9 kg less milk in the first 100 DIM compared with controls [44]. A second
study confirmed that the entire milk reduction occurs during the first
100 DIM [46]. No difference was observed between groups between
100 DIM and 240 DIM [44].
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BOVINE CESAREAN SECTION IN THE FIELD 291

Emphysematous fetus
Removing an emphysematous fetus by fetotomy is not always a viable
option. Of 159 dairy cows referred to the veterinary hospital for cesarean
section, 16 cows had emphysematous fetid6 cows (33%) survived and
were released from the hospital [38]. Typically these cows are toxic, pyrexic,
hypotensive, and in shock, requiring intensive management perioperatively.
Under ideal circumstances, these cows would be sent to a referral institution;
however, this is not always an option and must be managed on the farm.
Sedation, if required, must be used cautiously, because these cows are often
hypotensive. Preoperative antibiotics, anti-inflammatories, and fluid therapy
(hypertonic saline intravenously and oral fluids) are administered to stabilize
the cow’s cardiovascular system. In the author’s experience, minimizing ab-
dominal cavity contamination (by using a ventral approach, exteriorizing
the uterus, and changing gloves and instruments for abdominal wall closure)
has improved the prognosis for cow survival; however, cow fertility appears
to be poor.

Summary
The goals of the cesarean section are preservation of the cow and calf and
the future reproductive efficiency of the cow. The outcome of the cesarean
section is a self-filling prophecy. A number of variables may affect the suc-
cessful outcome of this procedure; case selection is the most important and
often overlooked variable. In addition, patient and surgeon preparation,
surgical technique, calf viability at the time of surgery, and exteriorizing
the uterus can affect outcome. Furthermore, good surgical technique in-
cludes gentle tissue handling, appropriate suture materials and patterns,
and adequate in-folding of the uterine incision to prevent leakage, combined
with antibiotics and anti-inflammatory medication when indicated, can help
minimize detrimental adhesions that may adversely affect the future repro-
ductive efficiency of the cow.

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