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Caesarean Section PDF
Caesarean Section PDF
Cesarean Section
Synonym(s): Surgical management of dystocia in cattle.
Introduction
• This article describes the technique used to perform a cesarean section and discusses the
decision making processes involved in determining when a cesarean section is
appropriate.
• Please be aware that this information is designed to be a useful guide for the veterinary
surgeon, but is not prescriptive. The decision making process will very much depend on
the individual case and its unique circumstances.
Uses
Maternal dystocia
• Expulsive defect/:
- Myometrial defect:
> Primary uterine inertia (inability of uterus to contract sufficiently).
> Secondary uterine inertia (decreased effectiveness of uterine contractions as
parturition progresses).
-Defective or inadeqate straining.
• Inadequate birth canal:
- Failure of cervix, soft tissues or ligaments to relax.
- Uterine torsion; definitely if complete torsion (>2700).
- Obstruction of birth canal, eg pelvic fracture.
• Inadequate pelvic diameter*
Fetal dystocia
• Fetal oversize:
- Normal but large*.
- Defective or monster calf.
• Faulty disposition or alignment:
- Abnormal presentation.
- Abnormal position.
- Abnormal posture.
• Fetal death.
• Signs of fetal distress.
Disadvantages
• Cost.
• Risk of surgical and post-surgical complications in dam, including death.
• May reduce subsequent fertility of dam.
• Anesthetic depression of calf (if sedative used).
Alternative techniques
Time required
Preparation
Procedure
• 30-90 minutes.
• Procedure should be performed as quickly and safely as possible.
Decision taking
Diagnosis of Dystocia
• Intervention in heifers:
- No significant progress made after 30 minutes of appearance of fetal membranes.
Risk assessment
Veterinarian expertise
New graduates should not be expected to perform this surgery without supervision.
Anesthetist expertise
• Veterinary surgeon may be required to perform some of the following anesthetic tasks:
- Sedation.
- General anesthesia.
- Epidural Epidural.
- Line block Line block.
-Inverted L block.
- Paravertebral blocks.
> Proximal block (Farquharson method).
> Distal Block (Magda method).
Nursing expertise
• The farmer or an assistant should be aware of the requirements for dealing with the
neonatal calf once it is removed.
Print out the farmer information sheet on: Caring for the cow and calf post
cesarean.
Other involvement
• The farmer should be aware of the requirement to not touch the surgical field unless ade-
quate surgical preparation of their person has been performed.
Materials required
Minimum equipment
Ideal equipment
• Sterile gloves.
• Sterile sleeves.
• Surgical gown.
• Drape.
• Surgical table/stand.
• Towels for neonate.
• Uterine forceps.
Minimum consumables
Preparation
Pre-medication
Pre-operative medications
• Once a decision to perform a cesarean section has been made NSAIDs should be
administered.
• See later for discussion on use of antibiotics.
• An Epidural Epidural, if not already performed, should be performed at this stage.
Dietary preparation
• If an elective cesarean is performed, feed restriction for 12 hours may help to prevent an
enlarged rumen.
Site preparation
Flank approach:
• Left flank preferable due to presence of rumen reducing risk of abdominal contents being
expelled.
• Large surgical clip; caudal to greater trochanter, cranial to last rib, dorsal to vertebral
processes, ventral to milk vein .
• Aseptic preparation of surgical area with suitable product (ie chlorhexidine or povidone
iodine) followed by surgical spirit.
• Local anesthetic blocks should be administered at this point. Paravertebral, line or
inverted L blocks are all suitable. If Line block or inverted L block Line block are used then
the surgical field must be prepared aseptically again.
• Sterile drapes can be placed around surgical site or disposable drapes placed and a
window cut to fit the surgical site.
Other preparation
Procedure
Approach
Procedure
Flank Approach
• The author uses a vertical skin incision, starting approximately 10cm ventrally to the
transverse processes and 10 cm caudal to the last rib.
• This is typically extended to a length of 30-40 cm ventrally.
- Incisions of up to 70cm may be required for large calves.
If further cesareans are likely then the incision should be made at the cranial border
of flank to allow for subsequent surgeries.
Care not to puncture the rumen which lies directly beneath the incision.
• Entry into the peritoneum is usually accompanied by the sound of air entering the
abdominal space.
• Variable amounts of peritoneal fluid may be apparent; this may appear blood-tinged .
Paramedian approach
• Incision made made halfway between midline and the subcutaneous abdominal vein.
• Incision extends from the level of the umbilicus to the mammary gland.
• Incision extended through rectus sheath and rectus abdominus muscle.
• Once inside peritoneal cavity method is same as flank approach.
Core procedure
• To aid exteriorization of a hindlimb the tarsus and foot can be held and used to lever the
uterus into the incision.
• The tarsus and foot then can effectively 'lock' the uterus at the dorsal and ventral aspects
of the incision.
• The use of Clenbuterol Clenbuterol prior to surgery will cause uterine relaxation and may
aid in the exteriorization of the uterus due to preventing the myometrium from
contracting when handled.
• The uterus is incised over the calf's leg from toe to carpus/tarsus .
• The incision should follow the greater curvature of the uterus and will ideally run parallel
to the longitudinal muscles of the myometrium.
• The incision should be as far from the cervix as possible to aid in closure.
• Avoid incising through any cotyledons as this can lead to profuse hemorrhaging.
• The incision can be made with a scalpel or scissors.
• It is vital that the incision is long enough, as if it is too short there may be uncontrolled
tearing of the uterus during extraction of the calf.
• The allantochorion and amnion can be ruptured manually and the calf's legs grapsed by
the surgeon.
• Once the legs are exteriorized these can be passed to an assistant.
- Sterile calving ropes or chains could also be attached and then passed to an assistant.
• It is advisable to direct the head of the calf out of the incision before too much traction is
placed on the forelimbs to prevent situations similar to a head back presentation which
may lead to damage of the uterus.
• The calf can then be delivered in a similar way to a normal delivery however the surgeon
should support the body of the calf as it is extracted so as not to put too much pressure
on the ventral aspect of the incision.
• The surgeon may also need to enlarge the incision if the calf is too tight. This incision
should follow the line of the initial one.
Step 5 - Care of the calf
• The surgeon should check for the presence of a second or third calf.
• The uterus should be exteriorized and examined for any tears or severe hemorrhage.
• Easily detachable fetal membranes should be removed and any excess membranes that
may impede closure can be trimmed with scissors.
Exit
• The uterus should be held by a sterile assistant or sterile uterine forceps should be
applied.
- The uterine forceps can then be help by a non-sterile assistant.
- It is possible for the surgeon to proceed with uterine closure without either of these
methods of assistance.
• Uterine closure should start at the cervical end of the incision.
• 6-8 metric Absorbable suture material (eg Catgut or Polyglactin) should be used, placed on
a round bodied needle.
• Partial thickness bites are taken using a continuous inverting pattern.
- Uttrecht pattern, Lembert pattern or Cushing pattern .
• Some surgeons will oversew this first layer with a second inverting pattern .
• Care should be taken not to include fetal membranes within the closure.
• Once the uterus is closed the surface should be cleaned of any debris or blood clots and
then returned into the abdomen.
• Excess free abdominal fluid can be removed and in the case of gross contamination can
be diluted with saline.
• The skin incision is closed using non-absorbable suture material (eg 5-7 metric nylon) on a
large cutting needle .
• Appositional suture patterns are preferred:
- Ford interlocking, simple continuous, cruciate or simple interupted pattern .
- If a continuous pattern is used it is advisable to place interrupted sutures in the ventral
aspect of the incision in case drainage is required.
- Some surgeons prefer an everting pattern for the skin, such as horizontal mattress. The
author does not use this suture pattern and is of the opinion that use of this pattern may
lead to reduced wound healing.
• Topical antibiotic spray or wound healing sprays can be applied to the incision line.
- It is the author’s opinion that such sprays have little effect, as antibiotics. However, silver
spray may reduce exudate, compared to antibiotic spray.
• Blood on the skin or surrounding hair should be washed off to reduce the urge of the cow
to rub the area as it dries and minimize the attraction of flies.
Aftercare
Immediate Aftercare
• Assess the status of the calf and advise the farmer if any form of resuscitation is required.
• The calf should be dried and the navel dipped as soon after delivery as possible.
• Once surgery is complete Colostrum Colostrum can be stripped from the dam and fed to
the calf by esophageal tube.
• The calf should be placed with the dam as soon as possible to ensure a good maternal
bond.
Dam post-operatively
Fluid requirements
Antimicrobial therapy
• Urogenital surgery is a clean contaminated surgery at best and therefore the use of
antibiosis is indicated.
• Potential contaminants are from the urogenital tract (mostly gram negative) or commen-
sals on the skin (mostly gram positive)
• A broad spectrum antibiotic is therefore indicated, ie Potentiated Amoxicillin.
• Ideally we want maximum tissue concentrations of antibiotics to be present at the time of
the first incision.
- This is not really possible in farm situations unless the antibiotic is administered prior to
the surgeon arriving.
• The use of antibiotics should always be carefully considered but it is the author’s opinion
that, until further evidence to the contrary is available, antibiotics should be used in
cesarean sections in cattle.
Potential complications
• Wound dehiscence.
• Retained fetal membranes Retained fetal membranes: removal.
• Metritis.
• Peritonitis.
Medication
Follow up
Outcomes
Complications
• Peritonitis.
• Wound breakdown.
• Abscessation.
• Mastitis.
• Retained fetal membranes.
• Metritis.
• Endometritis.
• Infertility.
Further Reading
Publications
Refereed Papers