SOFT TISSUE SURGERY 0749-0720/95 $0.00 + .

20

CESAREAN SECTION
Grant S. Frazer, BVSc, MS, and Nigel R. Perkins, BVSc, MS

In cases of bovine dystocia, the fetus may be delivered by mutation

and assisted vaginal delivery, partial or complete fetotomy, or cesarean
section. The experienced obstetrician should be proficient in all three
procedures in order to provide the best service for clients. Cesarean
section has become a common surgical procedure and there is a tendency
for both veterinarians and their clients to regard it as routine. It is
important to remember, however, that a cesarean section entails major
abdominal surgery, with inherent risks, irrespective of the prevailing
conditions or personnel involved. ll , 27

CASE SELECTION

Case selection is vital for successful surgical management of bovine

dystocias. Cesarean sections ideally should be reserved for instances in
which a live fetus cannot be delivered vaginally but, in practice, this is
not a realistic expectation. 14, 24, 32, 33
Excessive size of a live fetus relative to the maternal pelvic dimen-
sions is by far the most common indication for surgical intervention. 1, 6,
7,10,14,26 Causes of relative fetal oversize include premature breeding of

heifers, inappropriate crossbreeding, muscular hypertrophy, and pro-

longed gestation. 14 Other indications for cesarean section may include
severe anomalies in presentation or posture, fetal malformation (e.g.,
schistosomus reflexus), irreducible uterine torsions, uterine rupture, and
incomplete cervical dilation. The latter often actually is a cervix that is
constricting subsequent to a prolonged dystocia. 14, 24,30,33 The monetary
value of embryo transfer calves often dictates that an elective cesarean

From the Veterinary Medical Teaching Hospital, The Ohio State University (GSF), Colum-
bus, Ohio; and the Department of Veterinary Clinical Sciences, Massey University
(NRP), Palmerston North, New Zealand

VETERINARY CLINICS OF NORTH AMERICA: FOOD ANIMAL PRACTICE

VOLUME 11 • NUMBER 1 • MARCH 1995 19

20 FRAZER & PERKINS

section be performed under controlled conditions to minimize real or

perceived risks associated with natural delivery. 17, 29 In the authors'
experience, hydrops cases are best managed conservatively, with cortico-
steroids and prostaglandins. 32
If the fetus is dead, the authors consider a well-executed fetotomy
to offer optimal results in the majority of cases in which mutation and
assisted vaginal delivery are not successful. Fetotomy procedures are
aimed at reducing fetal size to facilitate vaginal delivery while avoiding
the problems associated with excessive traction. 2 Specialized equipment
and skills are necessary to correctly perform a fetotomy, however. Where
equipment is inadequate or if the attending veterinarian does not possess
the necessary skills, then cesarean section remains the primary alterna-
tive for fetal delivery. It should be noted that fetotomy is considered to
be contraindicated in prolonged cases where the uterus is tightly con-
tracted around a dead fetus, or if the cervix is dilated incompletely.32 In
some cases, delivery of an emphysematous fetus may be followed by
ovariohysterectomy as a means of salvaging a cow with irreparable
uterine damage. 9
The authors stress that a decision to perform a cesarean section
should be made as early as possible in the approach to a case of dystocia.
Cows that have been subjected to prolonged fetal manipulations or
unsuccessful attempts at fetotomy often are exhausted. They are not
considered to be good surgical candidates because of the trauma to, and
contamination of, the genital tract. 14, 31 In addition, surgical extraction of
the fetus can be extremely difficult if excessive traction per vaginum has
wedged it into the pelvic canal. 32

CHOICE OF SURGICAL APPROACH

Personal bias and professional experience influence the veterinar-

ian's strategy when a cesarean section is being contemplated. This
knowledge, together with an assessment of the patient (physical condi-
tion, breed, and demeanor), and the facilities available (e.g., chute for
restraint) ultimately govern the choice of surgical approach. 14, 15, 24, 32, 33
Owners often appreciate a ventral approach if early marketability is
desired. 21 Irrespective of other factors, ability to exteriorize the gravid
uterine horn is of paramount importance when dealing with an emphy-
sematous fetus or contaminated uterine fluids.1l, 20, 21, 24, 32 This is critical
because contamination of the peritoneal cavity with infected uterine
fluids is associated with a high risk of life-threatening peritonitis.
The surgical approaches for bovine cesarean section include:
Standing-flank (right or left)
Recumbent
Lateral-flank (right or left) Dorsal
-high -paramedian (right or left)
-low (ventral oblique) -ventral midline
 CESAREAN SECTION 21

Standing Flank
The standing flank cesarean section is the most common approach
for surgical delivery of a live fetus or a dead fetus accompanied by
minimal uterine contamination. 21, 24 Adequate restraint is essential and
should consist of a purpose-built bovine chute that permits the operator
to open the side or to remove side panels to facilitate access to the
flank region. Animals that are likely to become recumbent because of
exhaustion, obturator nerve paralysis, hypocalcemia, or toxemia are not
good candidates for standing surgery. Highly fractious beef cows may
be extremely difficult to manage during standing surgical procedures.
They may throw themselves down or struggle violently enough to risk
injury to the surgeon or calf and, in doing so, contaminate the surgical
field. 21 If a live fetus is present, then tranquilization should be ap-
proached with caution. ll , 14 The authors prefer not to use tranquilizers in
cows intended for standing surgery because they increase the risk of
recumbency. Xylazine, in particular, should be avoided because it causes
increased myometrial tone, which may make it difficult to manipulate
the uterus. 26 The standing flank approach provides relatively poor uter-
ine exposure and is contraindicated in the presence of contaminated
uterine fluid (prolonged dystocia; emphysematous fetus). Similarly, al-
though surgical correction of a uterine torsion is easier to achieve via
the standing flank approach, the suspected presence of an emphysema-
tous fetus is an indication for a ventral approach. 24
The choice of a left- or right-sided approach to the uterus depends
on the horn of pregnancy, facilities, level of assistance, and surgeon's
preference. In most situations, the practitioner would be best advised to
operate from the left side because the rumen acts as a barrier to contain
the intestines. 14, 15, 21 The approach from the right side does have specific
indications (e.g., extremely large fetus located in the right hom; irreduc-
ible clockwise uterine torsion). The major disadvantage is that intestinal
loops are liable to prolapse through a right-sided incision, with the
resultant trauma and contamination predisposing the cow to peritonitis
and ileus. In the authors' experience, this risk is minimized by having a
trained assistant to aid in manipulation of the uterus and abdominal
contents and by ensuring that the skin incision is made high in the right
paralumbar fossa.
Prior to preparing the surgical site, it is a good practice to tie the
tail away to the halter or opposite front leg. At no time should the tail
be tied to anything but the animal itself. As a precaution against the
cow lying down during surgery, a leg rope can be tied to the opposite
hindlimb, brought forward between the forelimbs, and tied to the halter.
If the animal does become recumbent during surgery, she will tend to
lie away from the surgical site. 26

Recumbent Approaches
Caution is advised when casting a cow in preparation for surgery.
A sudden or heavy fall may place excessive pressure on the gravid
22 FRAZER & PERKINS

uterus and can cause a distended, emphysematous uterus to rupture. 24

The authors prefer to use ropes for casting. 16 The front and hindlimbs
should be held extended by a rope, and the cow's head tied in a slightly
extended position. Although xylazine administration is useful for man-
agement and restraint of fractious animals, its undesirable uterotonic
effects in the cow can make manipulation of the gravid uterus difficult. 26
The authors believe that it should be avoided in bovine obstetrics when-
ever possible.

Lateral Recumbency-High Flank

In recumbent cows, factors similar to those for a standing cesarean
section govern the choice of a left- or right-sided approach. There is
increased abdominal pressure, however, and management of the intesti-
nalloops is especially problematic on the right side. A further disadvan-
tage of the right-sided approach is the increased risk of bloat and
regurgitation when the animal is positioned in left lateral recumbency.6, 33
A recumbent high flank approach is most suited to the delivery of
a live fetus from a cow that is not amenable to standing surgery (exhaus-
tion, fractious behavior, poor facilities). Even when the incision is started
more ventrally, in the paralumbar fossa, the extent of uterine exposure
is poor and there is an increased risk of fetal fluids entering the abdomi-
nal cavity. The leakage of noncontaminated uterine fluids is not consid-
ered to be associated with postoperative complications. If contaminated
fluids or an emphysematous fetus are present, however, then complete
exteriorization of the gravid horn is essential, making either a low flank
(ventral oblique) or ventral (paramedian or midline) approach a better
choice. IS, 21, 30, 31

Lateral Recumbency-Low Flank (Ventral Oblique)

The cow is positioned in lateral recumbency with the upper hind-
limb tied up and backward so an incision can be made between the
flank skin fold and udder attachment, extending cranioventrally from
the stifle toward the umbilicus21, 24 (Fig. 1). This approach provides
excellent uterine exposure, and is useful for delivery of emphysematous
and mummified fetuses and for repair of uterine lacerations that extend
close to the cervix. 32 The disadvantages of this approach are the amount
of tissue trauma, the difficulty in suturing the body wall incision, and
the potential for herniation. 6, 22, 30, 32

Dorsal Recumbency-Paramedian
The cow is cast and restrained in dorsal recumbency with both the
head and limbs tied in an extended position. The actual positioning is
more oblique than dorsal, with the cow's midline lying approximately
45 degrees from the vertical. This approach provides excellent uterine
exposure, with less tissue trauma than with a low flank (ventral oblique)
 CESAREAN SECTION 23

Figure 1. The cow is shown in a lateral recumbency position with the upper hindlimb tied
up and backwards so an incision can be made between the flank skin fold and udder
attachment, extending cranioventrally from the stifle toward the unbilicus. This approach
provides excellent uterine exposure.

incision. Herniation remains as a possible complication, however, and

assistance with leg rope restraint and positioning is required. It should
be noted that a grossly distended uterus may place excessive pressures
on the diaphragm. Thus respiratory compromise occasionally can be-
come a problem.

Dorsal Recumbency-Ventral Midline

This approach is preferred by the authors for extraction of an
emphysematous fetus when fetotomy is not an option. The animal is
positioned as for the paramedian incision. Under optimal conditions,
the amount of contamination of the abdominal cavity is negligible. The
thick fibrous linea alba provides an excellent anchor for the closing su-
tures.

ANESTHESIA

General anesthesia seldom, if ever, is indicated, and tranquilizers

should be used with caution if a live fetus is present?' 10, 11, 14,31 The
majority of cesarean sections can be performed satisfactorily under local
analgesia with appropriate physical restraint. 1, 14, 19, 24, 32 The use of xylaz-
ine as an aid for restraint is controversial in light of its known ability to
induce increased uterotonicity.12 The authors prefer not to use xylazine
24 FRAZER & PERKINS

for this reason but some veterinarians do use it routinely. 14, 18, 20 In
countries in which tocolytic agents are approved for use in food-produc-
ing animals, the uterotonic effects of xylazine can be blocked by the use
of f12-adrenergic agonists?' 10, 13 The most widely employed agents are
isoxsuprine and clenbuterol, but neither is licensed for use in cattle in
the United States. 12
Irrespective of the surgical approach, a caudal epidural block is
recommended to eliminate straining. This reduces the likelihood of
prolapse of the ruminal wall or intestines through the incision. 14 Excel-
lent surgical anesthesia for standing flank laparotomy is achieved by
performing a lumbar paravertebral block (T13, Ll-2). Alternatives are an
inverted /iLl! or line block. A thorough description of these techniques
was presented in a previous edition, and can be found in most surgery
texts. 25
A line block is most efficient for providing anesthesia prior to a low
flank, paramedian, or ventral midline surgical procedure. High epidural
anesthesia generally is not recommended because of the risk of musculo-
skeletal or mammary gland trauma as the cow recovers and attempts to
stand. 33 These risks are exacerbated if the cow is ataxic in the hindlimbs
from mild obturator nerve pressure, metabolic disease, or exhaustion
prior to surgery.

SURGICAL TECHNIQUE

The operative site should be clipped or shaved, then thoroughly

scrubbed and prepared for aseptic surgery.26 In a field situation, the use
of surgical drapes is at the surgeon's discretion, but it is useful to drape
the side of a chute to reduce the amount of contamination of the
exposed uterus.

Standing Flank

An initial 25- to 35-cm vertical skin incision is made in the mid-

paralumbar fossa starting approximately 10 cm below the lumbar trans-
verse processes. 14 Major vessels may be clamped with a hemostat, but
ligation seldom is necessary. The abdominal oblique muscles are incised
with a scalpel blade because a grid approach doesn't permit sufficient
access to the gravid uterus. Once the transversus abdominus is exposed,
the authors suggest using a pair of finger forceps to tent up the transver-
sus and peritoneum, and incising these layers with surgical scissors to
enter the abdominal cavity. Two fingers then are inserted through the
peritoneum to protect abdominal contents while the incision is extended.
The surgeon should wear a sterile shoulder-length sleeve before
inserting his or her arm into the abdominal cavity. An assessment of the
uterine wall's condition and fetal disposition is made. If the fetus is in
cranial presentation, the hock of one hindlimb is used to manipulate the
 CESAREAN SECTION 25

uterus and fetus toward the skin incision. The hand is gently cupped
behind the distal tibia just proximal to the hock and the hindlimbs
elevated within the uterus. Whenever possible, direct grasping of fetal
extremities through the uterine wall should be avoided because of the
risk of penetrating the uterus. The other hand then is placed behind the
fetlock to guide the distal limb through the skin incision as the hock is
elevated. The hock may be supported by one hand while the other
manipulates the scalpel but, often, the hindlimb can be locked into the
ventral extremity of the incision. This is an especially useful technique
when operating without an assistant (Fig. 2). The distal limb of a large
fetus often is very difficult to elevate to the skin incision, and complete
exteriorization therefore may not be possible. This is especially true
when attempting to exteriorize a right horn pregnancy through an
incision in the left flank. 33
When the fetus is in posterior presentation, the surgeon is presented
with the head and forelimbs within the uterus. This can make the task
of exteriorizing a portion of the gravid horn much more difficult. 33 The
surgeon must grasp the forelimb directly through the uterine wall,
usually just proximal to the level of the fetlock. Caution is urged when
attempting to elevate the fetus to the incision site because of increased
risk of traumatizing the uterine wall.
The uterus is incised along the greater curvature. Placentomes
should be avoided, and particular care should be exercised so the fetus
is not incised as well. The incision usually is started over the fetal claws,

Figure 2. The hock may be supported by

one hand while the other manipulates the
scapel. Often, the hindlimb can be locked
into the ventral extremity of the incision.
This is an especially useful technique when
operating without an assistant.
26 FRAZER & PERKINS

then extended proximally to the level of the hock or carpus. 30 It is best

not to begin the incision too close to the tip of the uterine horn because
it is difficult to suture that area. The final length of the incision will be
governed by the size of the fetus. Although the incision is started with
a scalpel blade, it may be extended with surgical scissors, if necessary.26
The distal limbs should be freed from the fetal membranes so an
assistant can grasp them just proximal to the fetlock. The fetus invariably
is slippery and the application of sterile obstetric chains or ropes may
assist in applying upward traction. 31 As the fetus is elevated out of the
uterus, the surgeon should be ready to extend both the skin and uterine
incisions as necessary. Excessive stretching of the tissues surrounding
an inadequate flank incision predisposes the animal to postoperative
seroma formation. Likewise, traction on the fetus often causes a tear at
right angles to the original uterine incision if it is not of sufficient length.
Such tears are difficult to suture, and may increase the likelihood of
uterine adhesions. 1, 31, 32, 33
The umbilical cord ideally should be permitted to stretch and rup-
ture spontaneously. This may be controlled somewhat if the surgeon
holds the cord close to its abdominal attachment. Surgical excision is not
recommended because it impedes the normal retraction and contraction
mechanisms within the umbilical arteries. Excessive hemorrhage from
the umbilical vessels can be controlled by the temporary application of
hemostats. 1, 14
An attempt should be made to minimize the release of uterine
fluid into the abdominal cavity during surgery. This is facilitated by
exteriorizing the fetal extremities within the gravid hom prior to incising
the uterus. The surgeon should grasp the edges of the uterine incision
to support the uterus as the assistant extracts the fetus. If the fetus is
alive and/ or the uterine fluid is minimally contaminated untoward
sequelae seldom occur if some fluid is released into the abdominal
cavity. 1, 26 In cases of prolonged dystocia, however, the uterine fluid
usually is contaminated and should not be permitted to enter the abdom-
inal cavity. In these cases, exteriorization of the gravid horn is critical
because of the increased risk of peritonitis, and the surgeon should
consider one of the ventral recumbent approaches to optimize uterine
exposure.

Low Flank (Ventral Oblique)

An oblique skin incision is made along a line extending from the

stifle to the umbilicus. After the deep fascia has been separated, a
small incision is made in the rectus abdominus muscle and peritoneum.
Caution should be exercised because the distended uterus generally lies
immediately beneath the peritoneum. Two fingers then are inserted into
the abdominal cavity and used to protect abdominal contents as the
incision is enlarged. The omentum often must be drawn forward to
permit a sleeved arm to be placed under the uterus and an attempt
 CESAREAN SECTION 27

made to elevate the gravid horn out of the incision. 22, 24, 32, 33 Once again,
the incision may need to be extended before complete exteriorization is
possible. It may be helpful to push down on the lower edge of the
incision as the uterus is elevated.
If the uterus is massively distended by an emphysematous fetus,
extreme care is necessary during these manipulations because spontane-
ous rupture may occur. Similarly, a small incision made in a distended
emphysematous uterus often results in extensive tearing as the gas and
fetid fluid escape. 1, 31, 32 The authors therefore suggest that the initial
incision be a bold one.

Paramedian and Ventral Midline

A midline incision is made from immediately in front of the udder

to 5 to 7 cm beyond the umbilicus. 14,33 It can be extended further, if
necessary, to permit full exteriorization of the gravid horn. Paramedian
incisions may be made medial or lateral to the abdominal veins.14, 24 In
high-producing dairy cows, the lateral approach often is indicated be-
cause of the presence of large left-right anastomosing vessels. 21 ,33 Again,
the incision extends cranially from the udder as far as necessary to
exteriorize the gravid horn. 3D, 31 The subcutaneous tissues should be
dissected gently and, although minor blood vessels may be clamped,
larger ones generally warrant ligation. A small incision is made in the
rectus abdominus muscle (paramedian) or linea alba (midline) such that
two fingers can enter the abdominal cavity. The incision then is extended
using the fingers as a guide. 26 It may be necessary to pull the omentum
forward to permit a sleeved arm to pass under the gravid horn. It is
helpful to push down on the ventral body wall as the horn is elevated
into the incision. This generally facilitates full exteriorization of the
gravid horn. Manipulation and incision of the uterus should be the same
as described for the ventral oblique approach. 6, 26, 33

SUTURING

Uterus

Closure of the uterine incision should not begin until the surgeon
has thoroughly examined the entire uterus to ensure that a twin fetus is
not overlooked. Closure in the standing animal is facilitated by complete
exteriorization of the gravid horn once the fetus has been extracted. This
is achieved by elevating the gravid horn from underneath, such that
additional uterine fluids are expelled.
If the fetus was dead for some time, the fetal membranes may come
away from the caruncles readily, but if they are firmly attached, they
should be left in place. 1 It often is helpful to trim away some membranes
from the incision site prior to closure. 24 The uterus can involute very
28 FRAZER & PERKINS

quickly, so it is important not to delay suturing. Oxytocin should not be

administered until surgery is completed because uterine contractions
may initiate abdominal straining and interfere with the placement of
sutures. 24 Starting the suture line at the end closest to the uterine body
is recommended. Failure to do so may mean the surgeon will experience
difficulty in placing the final sutures in a rapidly contracting uterus.
The selection of an absorbable suture material is at the surgeon's
discretion; Polyglycolic acid (#0-#2 PGA), polyglactin, or catgut (#2 or
#3) are recommended. The influence of suture material on the incidence
of postoperative adhesions has been the subject of much debate. It now
is generally accepted that the major concern is that the suture material
should not be exposed-especially the knots. 1, 11, 14, 30, 31, 32 In a recent
survey of 45 practitioners, 96% used catgut to close the uterus?
Irrespective of the suture pattern used, it is very important to ensure
that fetal membranes are not inadvertently incorporated into the suture
line. The authors routinely use a single layer, continuous, inverting
pattern in a noncontaminated uterus, preferring the Utrecht suture pat-
tern as described by Turner and McIlwraith (Figs. 3 to 5).31 This pattern
(Fig. 6) provides an excellent seal with a single layer, and the authors
consider it to be superior to a single layer using either a Lembert or
Cushing pattern?,9
If contaminated fluids are present, a two-layered closure is indi-
cated. 7, 8,10,11,26,32,33 A Lembert pattern may be followed by a Cushing
pattern to ensure an adequate inverting closure. Irrespective of the

Figure 3. Start the Utrecht suture

pattern to ensure that the knot is
buried. Note suture placement
well above incision. (From Turner
AS, Mcllwraith CW: Cesarean
section in the cow. In Techniques
in Large Animal Surgery, ed 2.
Philadelphia, Lea & Febiger,
1989, pp. 277-283; with permis-
sion.)
 CESAREAN SECTION 29

Figure 4. As the suture line is

tightened, the initial knot is buried.
(From Turner AS, Mcllwraith CW:
Cesarean section in the cow. In
Techniques in Large Animal Sur-
gery, ed 2. Philadelphia, Lea &
Febiger, 1989, pp. 277-283; with
permission.)

Figure 5. Sutures are placed at

angle to the incision to create an
"interlocking" inverting pattern.
(From Turner AS, Mcllwraith CW:
Cesarean section in the cow. In
Techniques in Large Animal Sur-
gery, ed 2. Philadelphia, Lea &
Febiger, 1989, pp. 277-283; with
permission.)
30 FRAZER & PERKINS

Figure 6. The Utrecht suture pat-

tern is shown. This pattern pro-
vides an excellent seal with a sin-
gle layer.

suture pattern chosen, sutures should be placed well back from the
incision to ensure adequate serosal contact. The uterine wall may be
edematous and friable after a uterine torsion or an emphysematous
cesarean section. 1 In some cases, it may be difficult to achieve inversion
of the wound edges, with sutures tearing out as soon as tension is
applied. Simple appositional suturing may be all that is possible, but
postoperative complications from leaking uterine fluid are highly likely.
Repeated, low doses of oxytocin are especially important in such cases
to ensure that uterine involution aids in completing the seal.
Irrespective of the surgical site, it is imperative that time be spent
cleaning blood clots and debris from the serosal surface of the uterus.
Liberal application of sterile saline is ideal. ll , 24, 32 Special attention should
be paid to the ovary and bursa because blood clots often lodge there
and are likely to cause adhesions that may impair future fertility. An
attempt may be made to lavage the abdomi.nal cavity if contamination
has occurred. Some authors advocate intra-abdominal antibiotic medica-
tion, but appropriate systemic therapy probably is more crucial to the
final outcome.

Body Wall

Flank Incision
Approximately 73% of practitioners responding to a recent survey
closed the abdominal incision with catgut. 7 The authors routinely close
the peritoneum and transverse abdominal muscle with a simple continu-
ous suture of #2 chromic catgut. It is helpful to have an assistant push
in the opposite paralumbar fossa as the final suture is tied. This elimi-
 CESAREAN SECTION 31

nates excess air from the abdominal cavity and decreases the incidence
of postoperative emphysema at the surgical site. l l The two oblique
muscle layers then are closed with a single, continuous suture pattern.
In the authors' experience, the incidence of seromas is reduced if every
second or third suture is continued into the transversus abdominus
muscle. This serves to reduce the dead space between the muscle layers.
A third continuous layer may be placed in the subcutaneous tissues if
excessive fatty tissue is present. A continuous interlocking suture then
is placed in the skin using nonabsorbable suture materiaL26 The authors
routinely end the continuous suture 2 to 4 cm above the ventral limit of
the incision. One or two simple interrupted sutures complete the closure.
If a seroma develops at the incision site, these ventral sutures can be
removed to facilitate drainage without disrupting the entire suture line. l l

Ventral Oblique
The peritoneum, rectus abdominus muscle, and deep abdominal
fascia may be closed with a single layer of simple interrupted sutures
using #3 catgut. Tension sutures such as the far-near-near-far pattern
may be used to provide additional incisional security. Placing simple
continuous sutures and tying every 10 cm offers a time-saving compro-
mise without sacrificing much incisional integrity.6 Alternatively, the
three layers can be closed individually, remembering that the external
rectus sheath provides the strength in the closure of the body wall. The
skin is closed with a continuous, interlocking pattern using nonabsorba-
ble suture materiaL22, 26 This approach is prone to postoperative edema
and seroma formation, and the owner should be advised to watch the
cow closely for signs of wound breakdown.

Midline
Several techniques have been suggested to close the peritoneum
and fascia, including a continuous, overlapping mattress pattern14 or
simple interrupted sutures placed about 1 cm apart. 26 The authors advo-
cate the use of #3 chromic catgut in a far-near-near-far pattern. Excessive
tension on the suture line may cause tearing of sutures and difficulty in
apposing wound edges. The temporary application of large towel clamps
into each edge of the linea alba incision can be used to relieve the
tension while sutures are placed (Fig. 7). It may be helpful to preplace
several sutures at each end of the incision prior to tying. Once they are
tied, the next towel clamp may be removed to facilitate placement of
more sutures.
Nonabsorbable suture material has been suggested as an alternative
in cases in which maximal incisional security is required, but that may
result in an increased incidence of suture sinuses developing post opera-
tively.6, 14,24,33 The authors, on occasion, have used nonabsorbable suture
material (nylon or polyester) in cases in which gross contamination of
the abdomen and incision site occurred. The skin is closed using a
32 FRAZER & PERKINS

Figure 7. Temporary application of large towel clamps into each edge of the linea alba
incision can be used to relieve the tension while sutures are placed.

nonabsorbable suture in an interrupted cruciate pattern. A continuous

interlocking pattern is not recommended because it may be difficult to
remove from a standing cow.

SUPPORTIVE CARE AND POSTOPERATIVE

MANAGEMENT

Intravenous fluid therapy, a broad-spectrum antibiotic agent, and,

possibly, anti-inflammatory drugs should be administered prior to sur-
gery in cows suffering from endotoxic shock associated with a severe
dystocia. A biochemical profile is useful to assess metabolic and electro-
lyte status, with appropriate replacement fluids being initiated if neces-
sary.I Clinical hypocalcemia is a surprisingly uncommon postoperative
complication. lO Fluid therapy should be continued postoperatively until
the animal is hydrated and capable of maintaining a normal fluid and
electrolyte balance by oral intake.
Systemic antibiotic therapy is continued for 3 to 5 days in cases in
which concern exists about the status of the uterine fluid, or if the
surgical field has been contaminated. 33 Although not recommended for
intrauterine administration in the early postpartum period, penicillin is
a good choice for systemic therapy.4 Clinical signs of peritonitis may be
expected to occur between 3 and 4 days postoperatively. I, 6, 26 Heavy
growths of coliforms and clostridial organisms are obtained readily from
emphysematous fetuses. I The authors seldom administer antibiotics to
elective cesarean cases operated on in a hospital setting.
 CESAREAN SECTION 33

Low-dose oxytocin therapy (20-40 IV intramuscularly) frequently is

continued for up to 24 hours postoperatively to promote uterine involu-
tion and passage of the fetal membranes. Frequent administration of
low doses of oxytocin is reported to produce a more physiologic re-
sponse than larger doses. 5 One study showed that oxytocin injections
promote uterine contractions for several days postpartum. 5 In the case
of an elective cesarean section, where surgery often is performed prior
to the onset of first-stage labor, the authors administer only 20 IV
oxytocin postoperatively. Higher doses may place excessive pressure on
the suture line by inducing strong uterine contractions against a closed
cervix. It generally can be expected to dilate within 24 hours postopera-
tively.14
The fetal membranes usually are passed within 24 hours of surgery,
but it is not uncommon for them to be retained for several days. 1, 10, 11 In
one study of 133 cesarean sections, the fetal membranes could be re-
moved at surgery in 6 and were passed within 12 hours in an addi-
%
,

tiona I 59%. 7 The administration of prostaglandins to promote passage of

the fetal membranes is a controversial issue, and their efficacy in the
immediate postpartum period warrants further study.12
If obturator paralysis is suspected in a recumbent cow, hindlimb
hobbles should be applied to prevent excessive abduction during at-
tempts to rise. It also is important to provide deep bedding and a nonslip
floor for cows that exhibit a neuromuscular deficit postoperatively. This
minimizes the risk of a coxofemoral luxation, femoral neck fractures, or
tom adductor muscles occurring during attempts to rise. l Downer cows
should be rolled frequently to prevent the development of compartmen-
tal syndrome. They may be elevated by slinging to aid in recovery of
muscular function, although care should be taken to avoid excessive
stress on the suture line.
Intrauterine medication is a controversial issue and each case should
be judged individually. 1 The postoperative management of cows follow-
ing delivery of an emphysematous fetus, or of those with substantial
contamination of the uterine contents, should include intrauterine ther-
apy. These cases are prone to development of fetal membrane retention
and metritis. 32 Palpation of the uterus per rectum during the early
postoperative period provides much information regarding uterine invo-
lution. If the uterus is thick walled and linear rugae are palpable,
involution probably is normal, and uterine therapy may not be neces-
sary. The presence of a thin-walled, flaccid uterus that contains a large
volume of fluid is evidence of delayed uterine involution and metritis.
These cases generally respond well to uterine therapy. In the early
postpartum period, povidone-based oxytetracycline is the drug of
choice. 4 A minimum of 3 g should be mixed with saline and infused
into the uterus daily until normal uterine involution returns. The authors
caution against the use of propylene glycol-based products, or oxytetra-
cycline powders intended for oral medication. These products are irritat-
ing and may suppress the uterine immune response.
It is important that appropriate drug withholding periods be com-
34 FRAZER & PERKINS

municated to the owner. The owner should be instructed to monitor the

incision for heat or swelling. In uncomplicated cases, the skin sutures
may be removed in 2 weeks.

PROGNOSIS

Clients should be advised that although the expected death rate

following cesarean section is low «10% ), the condition of the cow prior
to surgery is a major determinant of the outcome. 1, 7, 11, 14,24,32 Animals
that have been in labor for more than 18 hours, those with a decompos-
ing fetus and atonic uterus, and those showing signs of endotoxemia
may have a mortality rate approaching 40 24,26 Common life-threaten-
%
•

ing complications include septic metritis, peritonitis, and acute endotoxic

shock (e.g., following reperfusion of a cyanotic uterus after correcting a
torsion).24 A thorough physical examination before surgery should per-
mit the clinician to give a reasonably accurate prognosis for postopera-
tive survival. The owner should be advised that, in complicated cases,
mere survival may not mean that the animal will represent an economic
proposition to maintain. Abdominal adhesions may affect gastrointesti-
nal function and lead to loss of body condition and depressed milk
production?' 10, 11, 28, 32
Future fertility is another important consideration. Postoperative
complications involving the reproductive tract include metritis, chronic
endometritis, salpingitis, bursitis, peritonitis, and adhesions. Postopera-
tive fertility after a routine cesarean section is suppressed by approxi-
mately 15% compared with a population of normally calving animals. 1
Similarly, cesarean section has been shown to increase the number of
services per conception and days open. 6, 11, 32 Studies evaluating cows
that have been rebred after a cesarean section have reported a 60% to
80% pregnancy rate, with a further 5% to 9% loss as a result of abor-
tion.1, 3, 23, 24, 26, 32

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Springs, KS, VM Publishing, 1972, pp. 5-50.
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 CESAREAN SECTION 35

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Address reprint requests to

Grant S. Frazer, BVSc, MS
Department of Veterinary Clinical Sciences
The Ohio State University
College of Veterinary Medicine
601 Vernon L. Tharp Street
Columbus, OH 43210-1089