Periparturient emergencies

Question 1

Uterine vs cervical/vaginal prolapse

Answer 1

When?
Uterine: postpartum
Cervical/vaginal: pre-partum, occasionally in oestrus

Emergency?
Uterine: yes
Cervical/vaginal: no

Life threatening?
Uterine: yes
Cervical/vaginal: not usually

Cotyledons visible?
Uterine: yes
Cervical/vaginal: no

Question 2

Cervicovaginal prolapses - Grade 1

Answer 2

• Small intermittent vaginal prolapse only present when animal lies down

Question 3

Cervicovaginal prolapses - Grade 2

Answer 3

• Continuous vaginal prolapse
• Can rapidly progress to grade 3
• Bladder may be included.

Question 4

Cervicovaginal prolapses - Grade 3

Answer 4

• Vagina and cervix continuously prolapsed with exposure of mucus plug which may liquify allowing ascending infection.

Question 5

Cervicovaginal prolapses - Grade 4

Answer 5

• Long standing grade 3 prolapse resulting in necrosis and fibrosis of mucosa
• May lead to peritonitis.

Question 6

Uterine prolapse risk factors

Answer 6

▪ Hypocalcaemia
– Reduced uterine tone
▪Difficult calving
– Dystocia
– Calving assistance
– Calving injury

Question 7

Cervical/vaginal prolapse tx

Answer 7

• Epidural
• Use gravity to help
  – If animal is recumbent place in sternal with hindlimbs ‘frog legged’
  -> Frog leg tilts pelvis slightly, but do not leave in this position after the prolapse has been replaced
  – If animal is standing, make sure is a flat or downhill surface (facing downhill)
• Clean prolapse
• Apply firm cranial pressure to the prolapsed vagina (+/- cervix) with
  a flat hand
• Prolapse will evert and replace
• Perform Bühner suture
• Give pain relief +/- antibiotics
  – Cat D (amoxicillin/oxytet)
  – If taken longer or not able to clean it effectively

Question 7

Cervical/vaginal prolapse risk factors

Answer 7

• Increased abdominal pressure e.g. multiple foetuses, obesity
• Hypocalcaemia (it’s effect on smooth muscle)
• Hereditary
• Limited exercise e.g. housed indoors, high stocking density

Question 8

Cervical/vaginal prolapse potential complications

Answer 8

▪Ruptured bladder
– Secondary to urethral occlusion
– If the bladder has retroflexed into the prolapse
▪ Ringwomb
– Failure of cervix to fully open at parturition
– May need C-sec
▪Ascending infection→placentitis and foetal death
– Grades 3 and 4
– Due to disruption of the mucus plug -> ascending infection into the uterus

Question 9

Uterine prolapse tx

Answer 9

• Epidural
• Use gravity to help
  – If animal is recumbent place in sternal
  with hindlimbs ‘frog legged’
  – If animal is standing, make sure is a flat or downhill surface
• Remove placenta and clean prolapsed uterus
  – Don’t tear the placenta away at the cotyledons (would cause trauma to the endometrium and haemorrhage)
• Starting at vulva, carefully use fists to massage the uterus back into place
• Ensure uterine horns fully everted
  – Otherwise risk of re-prolapse is high
  – Use wine bottle or warm water/saline
  -> If using water slowly push it in until get passive outflow
  -> Leave in place and it will expel on it’s own in 1-2d
• Give calcium and oxytocin + pain relief and antibiotics
  – AB always needed for this -> contamination and will definitely get metritis
  – Pen-strep or amoxicillin

Question 10

Uterine prolapse potential complications

Answer 10

▪ Haemorrhage
– Rupture of uterine artery within broad ligament
– Avoid excessive movement of animal
– Careful handling of everted uterus
▪Metritis
▪Reduced subsequent reproductive performance
– As the uterine environment is likely to take longer to get back to normal

Question 11

What is uterine torsion?

Answer 11

= Rotation of the uterus around it’s long axis

Question 12

Uterine torsion presentation

Answer 12

▪ History consistent with prolonged 1st stage labour/failure of progression
▪Early 2nd stage or late 1st stage parturition
– Very occasionally in late gestation
▪Twist can range from < 90° to 720°

Question 13

Uterine torsion diagnosis

Answer 13

▪Vaginal exam
– Folds palpable in vagina → in direction of the torsion

▪Rectal exam
– Broad ligament palpably stretched across uterus
-> Dorsal aspect → ligament stretched in direction of torsion
-> Ventral aspect → ligament stretched ventrally away from torsion

About 2/3 of cases are anti-clockwise

Question 14

Uterine torsion correction/tx options

Answer 14

▪ Manual de-rotation
– Only possible if can feel calf feet (i.e. < 360° twist)
– Grasp calf’s feet and swing calf until flips over
– Gyn-stickTM can help (but care as potential to break calf’s leg - placing higher up on the calves leg reduces the risk)
– Deliver calf per vaginum
– C-sec may still be needed

▪ Roll cow
– Deliver calf per vaginum
– C-sec may still be needed

▪Caesarean section

Question 15

Correction of torsion using rolling

Answer 15

▪Cast cow using Reuff’s method
– Long rope and assistance needed
▪Roll in same direction as twist (as viewed from behind)
– Anti-clockwise (left) twist – cast onto left side and roll over in anti-clockwise
direction
– Clockwise (right) twist – cast onto right side and roll over in clockwise direction
▪A board can be used to stabilise uterus
– “plank in the flank” (Schaffer method)

Important to keep momentum

Question 16

Episiotomy indications

Answer 16

▪ Useful if foetus will not pass through vulva and careful traction does not stretch soft tissues
▪ Oversized foetus
▪ Stenotic/inadequately relaxed vulva (e.g. scarring, congenital abnormality)
▪ Aids foetal passage
▪ Prevents uncontrolled tearing of the vulva

Question 17

Episiotomy procedure

Answer 17

▪ Make incision with scalpel at 10 o’clock or 2 o’clock position of vulva
– Epidural
– Start at mucocutaneous junction
– Dorso-lateral direction (oblique)
– Up to 10 cm length
– DO NOT make incision at 12 o’clock position (would cause a tear and recto-vaginal fistula

Question 18

Episiotomy wound closure

Answer 18

▪ Epidural needed (if not already done)
– Theorised that vulval tissues are desensitised during calving, but soon after they are not and so need an epidural for suturing
▪ Absorbable sutures
▪ Simple continuous pattern
– Skin closure pattern is surgeon choice
▪ Mucosal layer does not need sutures

Question 19

Perineal and vaginal tears summary

Answer 19

▪ Due to damage from foetal head/limbs → minimise risk with careful calving assistance
– Don’t rush
– Obstetric lube
– Episiotomy if needed
▪ Minor tears of the vulva are common and do not require treatment
▪ Minor vaginal tears are best left to heal by secondary intention.
▪Moderate tears resulting in prolapse of the bladder or peri-vaginal fat can be sutured
– More severe vaginal tears → 2nd and 3rd degree perineal tears

Question 20

1st degree perineal tear

Answer 20

• Skin and mucosa of vagina/vestibule/vulva affected only.
• Rarely require surgery.

Question 21

2nd degree perineal tear

Answer 21

• Full thickness tear of the vagina/vestibule/vulva but not the rectal wall or anus.
• Some disruption of fibromuscular tissues separating vagina and rectum may occur.

Question 22

3rd degree perineal tear

Answer 22

• Full thickness tear of the vagina/vestibule/vulva as well as the rectal wall +/- anus.
• There will be complete disruption of the recto-vestibular shelf resulting in a wide opening between the rectum and vagina.
• A rectovaginal fistula may be present.

Question 23

1st and 2nd degree perineal tear repair

Answer 23

▪Not emergencies
– Leave and reassess a few days after calving
▪Most heal by secondary intention
▪2nd degree tears may result in faecal contamination of vagina over
time→increase endometritis risk→reduced fertility
– Can be managed with a Caslick procedure if required

Question 24

3rd degree perineal tear repair - D1C

Answer 24

▪Delay surgery for 6-8 weeks
– Allows epithelialisation of defect
– Allows swelling to resolve→can identify normal architecture
– Immediate surgery (< 4 h post calving) also possible but poorer outcomes
▪Advise farmer to consider whether wants to cull the animal
– It is a very involved reconstructive surgery and often farmers choose to cull the animal instead
▪Surgical technique is not D1C→can be found in surgical texts

Question 25

3rd degree perineal tear repair - surgical prep

Answer 25

▪ Epidural
▪ Cleanse perineum and irrigate vagina
▪ Evacuate rectum with faeces and pack with large swabs/absorbent cloths cranial to defect

Question 26

3rd degree perineal tear repair - peri-operative care

Answer 26

▪ NSAID analgesia
▪ Antibiotic therapy is indicated
– Choose drug with efficacy against clostridial organisms e.g. penicillin

Question 27

Haemorrhage summary

Answer 27

▪Range from mild venous ooze to severe arterial bleeds
▪Mild bleeds self-resolve
– Rarely asked to see these
▪Mild to moderate uterine (endometrial) bleeding→Oxytocin
– Stimulate myometrial contraction
– 20–50 IU (2-5ml) IV
▪Arterial bleeds = emergency
▪ Myometrial contraction has a haemostatic effect and can help stop some bleeding

Question 28

How can you reduce the risk of haemorrhage?

Answer 28

• careful calving management

Question 29

1st aid advice for arterial haemorrhage

Answer 29

▪ Digital occlusion of offending artery if end can be found
▪ Pack vagina as tightly as possible
– Clean bedsheets/towels

Question 30

What to do with an arterial haemorrhage?

Answer 30

• Locate offending artery and clamp with haemostats
  – Leave in place for ~3 days
  – Nylon material can be tied to the haemostats and tacked to the animal to keep them in place

Question 31

What to do if you can’t find the arterial ends for an arterial haemorrhage?

Answer 31

▪ Pack vagina tightly
▪ Leave in place for ~3 days
▪Guarded prognosis
▪ Ex-lap is an option (flank approach) → risks associated

Question 32

Possible sequelae to haemorrhage

Answer 32

▪Hypovolaemic shock
– Treat with fluids initially → volume expansion
– Blood transfusion may be required
– > 10L blood lost

▪If bleeding into the abdomen animal might present as sudden collapse after calving
– No external bleeding
– Hypovolaemic shock
– Train farmers to check mucous membrane colour

Question 33

What can you use to help reduce oedema in a very oedematous uterine prolapse?

Answer 33

• cover it will sugar or salt

Question 34

Why is it best to leave vaginal tears to heal by secondary intention?

Answer 34

• It is difficult to suture the vagina and often causes more harm than good