Periparturient emergencies Flashcards
Uterine vs cervical/vaginal prolapse
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
Cervicovaginal prolapses - Grade 1
- Small intermittent vaginal prolapse only present when animal lies down
Cervicovaginal prolapses - Grade 2
- Continuous vaginal prolapse
- Can rapidly progress to grade 3
- Bladder may be included.
Cervicovaginal prolapses - Grade 3
- Vagina and cervix continuously prolapsed with exposure of mucus plug which may liquify allowing ascending infection.
Cervicovaginal prolapses - Grade 4
- Long standing grade 3 prolapse resulting in necrosis and fibrosis of mucosa
- May lead to peritonitis.
Uterine prolapse risk factors
▪ Hypocalcaemia
– Reduced uterine tone
▪Difficult calving
– Dystocia
– Calving assistance
– Calving injury
Cervical/vaginal prolapse tx
- 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
Cervical/vaginal prolapse risk factors
- 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
Cervical/vaginal prolapse potential complications
▪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
Uterine prolapse tx
- 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
Uterine prolapse potential complications
▪ 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
What is uterine torsion?
= Rotation of the uterus around it’s long axis
Uterine torsion presentation
▪ 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°
Uterine torsion diagnosis
▪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
Uterine torsion correction/tx options
▪ 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
Correction of torsion using rolling
▪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
Episiotomy indications
▪ 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
Episiotomy procedure
▪ 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
Episiotomy wound closure
▪ 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
Perineal and vaginal tears summary
▪ 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
1st degree perineal tear
- Skin and mucosa of vagina/vestibule/vulva affected only.
- Rarely require surgery.
2nd degree perineal tear
- 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.
3rd degree perineal tear
- 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.
1st and 2nd degree perineal tear repair
▪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
