Bovis ISSN 2398-2993

Cesarean Section
Synonym(s): Surgical management of dystocia in cattle.

Contributor(s): Paul Wood, Adam Martin

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.

*these two factors combined or separately can be described as fetomaternal disproportion.

Elective cesarean

• History of previous dystocia or cesarean.

• Predictable dystocia due to breed predisposition, eg Belgian blue cattle or misalliance, eg
heifer too small when mated.

Advantages of performing the procedure

• Increased chance of live calves if intervention performed early.

• Reduced chances of secondary complications to cow, eg peripheral neuropathies.

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

Alternative treatments for inertia

• Manipulation if reducable malpresentations.

• Manual traction of fetus.
• Correction of uterine torsion.
• Fetotomy/embryotomy if calf is dead.

Time required

Preparation

Assessing the situation

• Obtain a history for the dam:

- Expected due date.
- Primigravida vs multigravida.
- Problems during pregnancy.
- When were signs of first stage labor seen?
- What has the farmer observed since?
- What has the farmer done so far?
- Has the cow recieved any treatments?
- What are the farmer’s expectations/needs?
• Assess dam general status.
• Assess presentation, postion and posture of calf.
• Assess viability of calf.
• Assess environment for performing necessary procedure.
- Safe.
- Adequate lighting.
- Cleanliness.
- Good footing.
- Area to safely restrain cow.
Once decision to perform cesarean made

• Administer Epidural (if not done already for assessment of fetus).

Procedure

• 30-90 minutes.
• Procedure should be performed as quickly and safely as possible.

Decision taking

Criteria for choosing test

• Assessment of cause of Dystocia.

• History suggestive of fetomaternal disproportion.
• Presence of uterine inertia.
• Decision often a subjective assessment of the dam and calf status and experience of the
veterinary surgeon.
• Value of calf vs value of cow may play a deciding role.

Diagnosis of Dystocia

• Hugely variable gestation lengths between breeds and sires.

• Records not always reliable, particularly in beef systems.
• Intervention in cows:
- Stage two labor lasting for greater then one hour.
- There are a lot of conflicting statements in the literature, as to the normal length of stage
2 labor.
> Published lengths range from 1-2 hours (heifers), 0.5 – 1.5 hours (cows) to some that
say normal stage 2 in cows should be less than an hour. There is also some literature
which considers earlier intervention as a producing a better outcome for cow and calf.
> The advice here reflects the author’s personal opinion and cases should be assessed on
an individual basis. Emphasis should be on noticing whether the labor is progressing, over
the time period in question.

• Intervention in heifers:
- No significant progress made after 30 minutes of appearance of fetal membranes.

• General reasons for intervention:

- Weak or infrequent abdominal straining.
- Absence of abdominal straining.
- Obvious fetomaternal disproportion or obstruction.
- Signs of systemic illness.
- Evidence of fetal death.
- Meconium visible as vulval discharge.

Risk assessment

• Risk of fetal death.

• Risk of cow death.
• Safety of environment for performing procedure.
Requirements
Personnel

Veterinarian expertise

• The veterinary surgeon needs to be confident in their abilities to:

- Diagnose dystocia.
- Perform anesthesia (general or local).
- Perform this surgery confidently.

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

• Halter or other restraint.

• Clippers or razor.
• Surgical scrub.
• Surgical spirit.
• Clean/Surgical waterproof clothing.
• Surgical kit.

Ideal equipment

• Sterile gloves.
• Sterile sleeves.
• Surgical gown.
• Drape.
• Surgical table/stand.
• Towels for neonate.
• Uterine forceps.

Minimum consumables

• Local anesthetic Local anesthesia.

• Non-steroidal anti-inflammatories Anti-inflammatory drugs.
• Antimicrobial.
• Appropriate needles and syringes.
• Suitable scalpel blade.
• Absorbable suture material.
• Non-absorbable suture material Suture materials: overview.

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

• Aseptic preparation of surgeon.

• Sterile gowning, gloving and preparation of surgical kit .
Restraint

• If flank approach then cow should be haltered to a solid structure.

• The non-surgical flank should be against a solid wall or gate.
• The tail should be loosely tied to the rear leg.
• Ratchet straps can be used to secure the cow to a gate on the non-surgical side to prevent
lateral movement during the procedure.
• If ventral approach the cow should be sedated or placed under general anesthesia and
then cast using ropes; once cast the cow can be turned into dorsal recumbancy and the
hind limbs secured for surgeon safety. The ventral approach has never been undertaken
by the authors and is not discussed in this article.

Procedure
Approach

Procedure

Flank Approach

• The adequacy of local anesthesia should be tested prior to surgery.

• Adequate time must be left between local anesthetic block and commencement of sur-
gery.
• Muscle layers and peritoneum may stay sensitive despite skin desensitization.
- If this happens then “top-up” anesthesia may be required, with due attention paid to
sterility at this time.

Step 1 - Skin incision

• 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.

Step 2 - Incision through muscle layers

• Cutaneous, external abdominal oblique, internal abdominal oblique and transverse

abdominal muscles will be incised.
• Incision can be by scalpel or once an initial entry point has been made the surgeon may
switch to the use of surgical scissors.
- This reduces the likelihood of cow movements leading to trauma of internal tissues/
organs but may cause slower tissue healing.
• Hemorrhage from muscle layers is usually minimal however if large vessels are observed
then hemostats should be applied and the vessel ligated if necessary.
• The peritoneum can be incised with a scalpel and then extended with surgical scissors.

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

Step 1 - Exploration of the abdomen

• Identify uterus and disposition of the calf.

• Identify a distal extremity of the calf and with gentle traction of this limb the uterus can be
exteriorized.

Step 2 - Exteriorization of the uterus

• 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.

Step 3 - Uterine incision

• 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.

Step 4 - 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 live calf should immediately be attended to by an assistant.

Step 6 - Further checks

• 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

Step 1 - Closure of uterus

• 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.

Step 2 - Peritoneal and muscle closure

• Approach to peritoneum and muscle layer closure varies amongst surgeons.

• Absorbable suture material on a round bodied needle should be used in a continuous
pattern.
• Each layer can be closed individually, in pairs (peritoneum and transverse muscle layer;
internal and external abdominal obliques) or all together.
• - This author prefers to suture the peritioneum and transverse muscle layer together,
followed by both abdominal obliques individually.
• It is important to include a good bite of peritoneum in each throw of suture for the first
layer.
• To reduce dead space between muscle layers occasional deeper bites into the underlying
muscle layer can be made.

Step 3 - Skin closure

• 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.

Step 4 - Post operative cleaning

• 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

Care of the Calf

• 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

• Check udder for presence of colostrum and teat function.

• If involution of the uterus was not occuring at point of closure then Oxytocin can be
administered.
- This will also assist with milk let down.
• Calcium borogluconate can be administered intravenously or subcutaneously if there are
concerns about Milk fever Milk fever.

Fluid requirements

• If evidence of shock then intravenous Fluid therapy can be administered.

- 2-3 litres of hypertonic (7.2%) sodium chloride given intravenously followed by access to
fresh drinking water.
- If the cow does not drink then 20 litres of water can be administered via stomach tube/
pump.

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.

Long term Aftercare

Medication

• Repeat NSAID treatment after 48-72 hours if necessary.

• Treat any surgical site infections.

Follow up

• The dam should be examined 24-48 hours after surgery .

• Pyrexia, depression, innappetance and diarrhoea may indicate the presence of peritonitis.
• Sutures can be removed 10 – 21 days following surgery.
• A postnatal check of the genital tract can be performed at this time.
• Fertility may be affected following caesarean which may delay conception.

Outcomes
Complications

• Peritonitis.
• Wound breakdown.
• Abscessation.
• Mastitis.
• Retained fetal membranes.
• Metritis.
• Endometritis.
• Infertility.

Reasons for treatment failure

• Initial case selection and decision making.

• Contaminated surgical site (including presence of a dead fetus).
• Poor surgical technique.
• Wound dehiscence.
• Toxic shock.
• Any delay in procedure that results in death of viable fetus.
Prognosis

• Generally good but heavily dependent on case selection.

• Dependent on individual animal, farm and surgeon.

Further Reading
Publications

Refereed Papers

• Recent references from PubMed and VetMed Resource.

• Hendrickson D A & Baird A N (2013) Cesarean Section in the Cow. In:
Turner and McIlwraith’s Techniques in Large Animal Surgery. Wiley Blackwell. pp 258-265.
• Lyons N A et al (2013) Aspects of bovine caesarean section associated with calf mor-
tality, dam survival and subsequent fertility. The Veterinary Journal PubMed.
• Newman K D (2008) Bovine caesarean section in the field. Veterinary Clin of North Ameri-
ca: Food Anim Pract 24, 273-293 PubMed.
• Schultz L G et al (2008) Surgical approaches for caesarean section in cattle. Canad Vet
Jour 49, 565-568 PubMed.
• Kolkman I et al (2007) Protocol of the caesarean section as performed in daily bovine
practice in Belgium. Reproduction in Domestic Animals 42, 583-589 PubMed.
• Newman K D & Anderson D E (2005) Cesarean section in cows. Veterinary Clinics of North
America: Food Animal Practice 21, 73-100.
• Fubini S L & Ducharme N G (2004) Cesarean Section. In: Farm Animal Surgery. Ed:
Fathman E M. Saunders. pp 382-387.
• Noakes D E, Parkinson T J & England G C W (2001) The caesarean operation. In: Arthur’s Vet-
erinary Reproduction and Obstetrics. pp 341-363.
• Dawson J C & Murray R (1992) Caesarean sections in cattle attended by a practice in
Cheshire. Veterinary Record 131, 525-527 PubMed.
• Barkema H W et al (1992) Fertility, production and culling following caesarean section
in dairy cattle. Theriogenology 38, 589-599 PubMed.
• Cattell J H & Dobson H (1990) A survey of caesarean operations on cattle in general
veterinary practice. Veterinary Record 127, 395-399 PubMed.
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