Complicated C-section in a Holstein Cow
Julie Ryckbost Clinical Advisor: Dr. Rob Gilbert Basic Sciences Advisor: Dr. John Hermanson
Senior Seminar Paper Cornell University College of Veterinary Medicine
10 March 2010

Abstract A 7 year old black and white Holstein cow presented to Cornell University’s
emergency service with a 3 day history of inappetence, decreased milk production, foul vaginal discharge, and abdominal distention since calving. Problems on physical exam included: dehydration, right abdominal distention, right sided tympany, foul vaginal discharge, and a large fetus present in a large, fluid-filled uterus. Routine serum chemistry revealed hypocalcemia, hypochloremia, and alkalosis. Fluid obtained by abdominocentesis had elevated total protein concentration. Surgery was elected after stabilization of the patient. Fluids and antibiotics were administered and a C-section was performed using the ventrolateral approach. A large emphysematous fetus was removed. The cow became febrile 3 days after surgery, and her antibiotics were changed because of suspected peritonitis. She improved over the subsequent 3 days and was discharged. Her incision became infected after discharge but both her peritonitis and incisional infection resolved with prolonged antibiotic use on the farm. Signalment and Case History
A 7 year old black and white Holstein cow presented to the Cornell University Farm Animal Hospital emergency service for evaluation of decreased appetite, decreased milk production, and abdominal distention of 3 days duration. The cow calved unassisted 3 days prior to presentation, and it was unknown if she passed her placenta. Subsequently, she developed signs of metritis, including foul smelling vaginal discharge. Her appetite decreased over the 3 days prior to presentation, and she was completely anorexic the day she presented to Cornell. Her milk production was also severely depressed and she had right sided abdominal distention and right sided

tympany. She was treated on the farm with 3 bottles of CMPK drench (Durvet), 1 liter of calcium borogluconate (Wyeth), Rumen Yeast Caps (Techmix), magnesium oxide pills, flunixin meglumine, 1 liter of 7% saline IV, and B vitamins IV. She did not improve and was sent to Cornell for correction of a suspected right displaced abomasum (RDA). Physical Examination
On presentation, the cow was quiet, alert and responsive. She had sunken eyes and decreased skin turgor. Her respiratory rate was 24 breaths per minute, heart rate was 56 beats per minute, and temperature was 100.6 degrees Fahrenheit, all within normal limits. Her heart sounds were normal, her mucous membranes were pink, and her capillary refill time was <2 seconds. No abnormal respiratory sounds were ausculted. She had right sided abdominal distention, both dorsally and ventrally and right sided tympany. Rectal exam revealed a large fluid and gas filled uterus, and a fetus still present. Vaginal exam revealed foul smelling discharge, and a cervix that was too closed to pass more than two or three fingers through.
Serum chemistry revealed hypocalcemia, hypochloremia, and a metabolic alkalosis. The hypochloremic alkalosis was attributed to the magnesium oxide pills that she received on the farm. Abdominal ultrasound confirmed a large fluid-filled uterus and a fetus still present, which was confirmed to be dead. Abdominal ultrasound also revealed that the abomasum was of normal size and in the correct position in the ventral aspect of the abdomen. Abdominocentesis was performed which revealed a normal cell count (2,300 cells/ul) and an elevated total protein concentration (3.7g/dl).

Problem list The patient’s problem list after history, physical exam, and ancillary diagnostics
included: anorexia, decreased milk production, dehydration, abdominal distention, right sided tympany, physometra, fetus present, foul vaginal discharge, hypochloremia, metabolic alkalosis, hypocalcemia, and increased peritoneal fluid total protein. Differential diagnoses
Based on history alone, the most likely differential for the patient included a right displaced abomasum (RDA). It is plausible that metritis could have caused her to go off feed, and result in an RDA causing the rest of her clinical signs. However, on presentation, clinical signs were not consistent with an RDA. She had a normal temperature, respiratory rate, and heart rate, which are expected to be elevated due to toxemia generally present with an RDA. Her other top differential included a large, fluidfilled uterus based on her history of recently calving. Other, less likely differentials, included causes of abdominal distention such as vagal bloat and pneumoperitoneum. These latter two differentials were lower on the list because of the appearance of the abdominal distention. The patient was only distended on the right, and one would expect both right and left distention in the cases of bloat and pneumoperitoneum. Physical examination ruled out an RDA, bloat, and pneumoperitoneum once the presence of a large, fluid filled uterus and calf was revealed and the physometra was determined to be the cause for the right sided tympany. Physical exam and ancillary diagnostics allowed us to make the diagnosis of metritis along with the presence of an emphysematous fetus.

Prognosis The patient was given a guarded prognosis due to the high risk of post operative
complications including peritonitis, adhesions, and incisional infection. Prognosis for cows with emphysematous fetuses ranges based on the cow’s physical condition at the time of surgery. If they are stable with minimal electrolyte and blood gas disturbances, it goes without saying that their prognosis is much better than a cow that is in septic shock. In general, it has been demonstrated that cows having undergone C-sections (both planned and emergency) have a longer interval from first service to conception, lower milk production in the first 100 days in milk, and a higher risk of being culled than cows that calved normally. In addition, the chance of being culled for fertility problems, calving problems, and low production, is higher for cows that have a C-section than for those with normal deliveries[1]. Treatment
Because of her closed cervix, the decision was made to perform a cesarean section the following day, after correction of her electrolyte and acid/base abnormalities. To date, there are no available drugs able to dilate a closed cervix in cattle and in this case, the only method of removing the cow’s calf was via cesarean section. The cow was given a bottle of 7% saline intravenously, followed by a bolus of 10L of Plasma-Lyte (Baxter) with 20meq KCl/L added. She was also given500mL of calcium borogluconate subcutaneously. She was maintained on IV fluids overnight, and she was also started on procaine penicillin G (PPG) (22,000U/kg SC) and Naxcel (2.2mg/kg IV).
On the day of surgery, the cow was quiet, alert, and responsive. Her physical exam was unchanged except she now had tympany over the para lumbar fossa on both

the left and right. Serum chemistry showed mild hypocalcemia and hypokalemia so her IV fluids were supplemented with 40meq KCl/L and she was given one bottle of calcium subcutaneously.
The patient was sedated with 50mg of intravenous xylazine and given 5mg of butorphanol for pain control. She was placed in left lateral recumbency and her legs were secured to hold her in this position. A local block was administered in an inverted L pattern using 2% lidocaine. A 40cm skin incision was made with a #22 blade, coursing parallel to the superficial mammary vein, then angling dorsally at the udder. The muscle layers were sharply incised using a #10 blade. Hemostasis was achieved by ligation. Upon opening of the abdomen, the large uterus was present at the incision and the emphysematous fetus was palpable. The uterus was partially exposed through the incision, and a moist towel was placed under the uterus to prevent contamination of the abdomen. A #10 blade and curved Mayo scissors were used to make a 25 cm incision in the greater curvature of the uterus. The hind feet of the calf were identified and chains were applied around the fetlocks and pasterns. A dead bull calf was then pulled from the uterus. The uterus was lavaged thoroughly with sterile physiologic saline, and the blood clots were gently rubbed off with a gloved hand to minimize adhesion formation. The uterus was closed in two layers. The first layer was closed with #2 chromic gut in a simple continuous pattern which was then oversewn using #2 chromic gut in the inverting Utrecht pattern. The peritoneum and muscle layers were closed separately using #1 Vicryl in a simple continuous pattern. The skin was closed using #1 Supramid in a ford-interlocking pattern. The cow was given 2cc of oxytocin post operatively to aid in expulsion of placental remnants and encourage uterine

contraction. The cow had difficulty rising after surgery, and fell onto her sternum, causing her front limbs to abduct forcefully. She was given a bottle of calcium, half IV and half subcutaneously. She stood with assistance, and upon standing, she was lame on the right front limb, but was able to walk back to her stall with help. Her IV fluids and antibiotics were continued overnight.
The reason that the cow had one normal calf and did not continue on to have her twin is speculated to be due to uterine inertia. In dairy cattle, uterine inertia causes about 5% of dystocias. We speculate that the patient was suffering from primary uterine inertia caused by low levels of ionized calcium in the blood. This is consistent with the hypocalcemia we discovered on presentation. With mild hypocalcemia, the cow could have had her first twin and been unable to have her second twin due to lack of Ca++ available for appropriate smooth muscle contractions of the uterus. The calf was also malpresented, but this is often secondary to uterine inertia, because uterine contractions are what stimulate the righting reflex of the fetus. Had someone checked for a twin, the cow’s situation would have been avoided. However, because the uterine inertia ceased her straining, and because she had one normal calf, it appeared to anyone involved that labor was over. Her case is a perfect example of why cows should always be checked for a twin, as twins are not uncommon in this species. Outcome
The night of surgery, the patient was unable to get up on her own, she had a poor appetite, and spent most of her time in sternal recumbency. She was continued on her IV fluids, PPG, Naxcel, and Banamine. The next day she was still unable to get up unassisted due to her injury obtained on recovery, she was hypoglycemic, her blood

Ca++ was low normal, and her hypokalemia had resolved. She was given 500mL of calcium SQ, 500mL of dextrose IV, and her IV fluids were supplemented with 20mEq/L of KCl and 2.5% dextrose to help maintain her blood glucose and potassium levels within normal limits. She began to get up on her own that day, but she also broke with watery diarrhea, and her heart rate became elevated (92bpm). The next day, 2 days after surgery, no abnormalities were noted on serum chemistry. She needed assistance getting up, but was able to walk unassisted and was still lame on her right front leg. Her appetite improved and she ate and drank well throughout the day. Her antibiotics and fluids were continued. On the third day after surgery, the patient became febrile with a temperature of 104.2 degrees Fahrenheit, and had an elevated heart rate of 90bpm. She began passing normal feces, and continued to have a good appetite. On day 4 after surgery, her temperature was still elevated at 105.1F. Her antibiotics were changed from penicillin and Naxcel to IV oxytetracycline (10mg/kg IV BID, diluted in 1L saline). She was also administered 1L of hypertonic saline IV to encourage drinking. She was able to get up and stand on her own, but preferred to lie in sternal recumbency. On the fifth day after surgery, her fever decreased and fluctuated between 101.5 and 103.0F. She was brighter and had a good appetite, normal rumen motility, and normal manure. Transrectal ultrasound of her uterus revealed fluid present, but not more than what was expected given her condition. On day 6 after surgery, the patient continued to do well, was able to get up on her own, had a very good appetite, and continued to pass normal manure. She was producing approximately 30 pounds of milk per day and her temperature remained within the normal range. She still had foul smelling vaginal discharge, but it had decreased each

day following presentation. She was discharged into the care of her owner that day. The cow was sent home on oxytetracycline (12,000mg every other day) with instructions to keep her on antibiotics until her temperature stayed within normal range for 3 consecutive days. She was also sent home with instructions to have the RDVM administer 2 prostaglandin shots, 10 days apart, because she had some retained fetal membranes. Follow up
The cow did well after discharge and her antibiotics were discontinued about seven weeks after surgery. At this time she was milking 110 pounds per day. She still had some fluid in her uterus but according to the RDVM, the uterus felt good and was making good progress. Her incision became infected after discharge, and was being managed by flushing the incision once a day. Because of the fluid still present in her uterus, her owner had not attempted to breed her back as of 7 weeks after surgery. Discussion
A ventral approach with the cow in lateral recumbency is ideal when dealing with emphysematous fetuses because of the high risk of abdominal contamination. According to Newman et al. (2005), cows with emphysematous fetuses can be managed successfully in as many as 80% of cases when using a ventrolateral approach and intensive medical treatment. However, one retrospective study found that only 33% of cattle with emphysematous fetuses that presented to a university hospital lived to discharge. Individual cows can have a very different prognosis due to varying states of health at the time of surgery. They are often toxic, hyoptensive, and in shock, and must be managed accordingly periopertively[2].

The ventrolateral approach, with the cow positioned in lateral recumbency, is best in these cases because it aids in exteriorization of the uterus and thereby minimizes abdominal contamination with uterine fluid[3]. This is imperative when dealing with an emphysematous calf and contaminated uterine contents. The ventrolateral approach has the advantage in dairy cows with large udders, of being able to extend the incision further caudally than with a midline or paramedian approach[4]. However, this approach is more prone to incisional herniation than the flank approaches and even the ventral midline and paramedian approaches because the closure is less secure. This risk is due to the structures involved in closure--the apneuroses of the external and internal abdominal oblique mm and the transversus muscle fibers. This closure has less holding strength than the linea alba or the rectus sheaths which are involved in a paramedian approach[4]. Any ventral approaches are more prone to herniation than flank approaches due to the weight of abdominal contents pressing on the incision. The ventrolateral approach is also more prone to incisional infections than any other approach because the incision is in close proximity to the ground. It also has the disadvantage of being difficult to close because of high degree of tension on the apenuroses and muscle layers previously mentioned[3].
The type of uterine closure depends on the reason for the c-section. In surgeries with minimally contaminated uterine contents, a single layer partial thickness closure using an inverting pattern such as the Utrecht is sufficient. However, when the uterine contents are contaminated, especially with emphysematous fetuses, a 2 layer closure is recommended, using a continuous inverting pattern such as Cushing, Utrecht, or Lembert. One method taught at Cornell is closing the first layer with a simple

continuous pattern, incorporating all layers of the uterus, then oversewing that with an inverting pattern.
Along with incisional infections, common post-surgical complications of cesarean section in cattle include adhesion formation and peritonitis. The latter is of much greater concern when dealing with an emphysematous fetus than a live calf with minimally contaminated uterine contents. Adhesions begin with extravascular blood which forms clots on serosal surfaces and incisions. There are fibrin strands in all clots that become stabilized by plasma transglutaminase. This is what forms fibrinous adhesions. If these are not broken down quickly, or are too extensive, they become invaded by fibroblasts and become fibrous adhesions. Fibrous adhesions are much tougher than fibrinous adhesions, and they may lead to complications such as entrapment and strangulation of loops of bowel, or difficulties exteriorizing the uterine horn in subsequent c-sections. The key to minimizing adhesions during surgery is proper tissue handling techniques, especially being sure to remove extravascular blood clots via physiologic saline lavage and manual removal with a gloved hand, and burying suture knots. Administering antiinflammatories such as flunixin meglumine also aids in the prevention of adhesions[2].
Peritonitis is a complication of great concern when dealing with an emphysematous fetus and contaminated uterine contents. Abdominal contamination can be minimized by using a ventral approach that facilitates exteriorization of the uterus and calf. However, abdominal contamination is virtually impossible to avoid, and may also come about pre-operatively due to compromise of the uterine wall[2]. Clinical signs appear 3-4 days after surgery and include fever, inappetance, decreased milk

production, and diarrhea, all of which our patient began to display 3 days postoperatively.
The choice of anesthesia used for cesarian sections in cattle depends on the situation. Various methods of local anesthetic are acceptable and depend somewhat on surgical approach. Common techniques include proximal and distal paravertebral, inverted L, and line blocks, all using 2% lidocaine hydrochloride. Sedation is trickier, as too much of a sedative may cause the animal to become recumbent during the procedure, but not enough will provide a challenge to the surgeon who has to deal with a fractious animal. Xylazine is a commonly used anti-anxiolytic and analgesic for csections in dairy cattle. However, Shultz et al (2008) caution against using xylazine, as it has a direct myotonic effect on the uterus, causing contractions and increasing difficulty in exteriorizing the uterus. This in turn leads to increased risk of contaminating the abdominal cavity, and increased risk of uterine tears during closure. However, difficulty in exteriorization of the uterus less of a concern with approaches that lend themselves to ease of exteriorization, specifically the ventrolateral approach.
Caudal epidural anesthesia is used if previous obstetrical procedures or the calf itself have caused strong uterine contractions. Typically 2% lidocaine is used, and as long as the dose of 0.5ml/50kg is not exceeded, the epidural should not affect motor function of the hind limbs and cause the animal to become recumbent during the procedure[2]. A comparison of various approaches Left or right standing flank

This approach is commonly used due to surgeon familiarity of flank surgery in cattle. Case selection is important and this approach is generally recommended if it is likely that the cow is going to remain standing through the whole procedure, and if the calf is still viable or has recently died. The left side is generally favored over the right because the rumen acts to prevent intestine or other smaller viscera from protruding through the incision. The cow is locally anesthetized using the anesthetic pattern of the surgeon’s choice appropriate for flank surgery in a cow, along with an epidural if desired. The incision is started 10-15 cm ventral to the transverse processes of the lumbar vertebrae, and extended ventrally 30-40 cm. A fetal limb is localized (pelvic if the fetus is in anterior presentation, thoracic if it is in posterior presentation) and the fetus is rocked to bring the uterine horn to the incision. The limb is then locked into the incision and the uterus is incised over the greater curvature in order to avoid prominent blood vessels. The placenta is opened and an assistant uses gentle traction on the limbs to withdraw the fetus, while the surgeon maintains traction on the uterus to keep it exteriorized. The uterus is closed as described previously and the body wall is closed routinely. A right sided approach may be chosen if there is severe ruminal distention or a large fetus is present in the right horn. The main disadvantage of a flank approach is the risk of the cow becoming recumbent during the procedure and contaminating the surgical site[3]. It is also not the best approach for a fractious dam, an oversized fetus, or an emphysematous fetus, as a ventrolateral approach will allow better exteriorization of the uterus[2]. Ventral midline

This approach is generally used when an inconspicuous scar is desired or when it has been determined that the dam will not remain standing, or is already recumbent. The cow is placed either in dorsal recumbency, or at a 45 degree angle, as dorsal recumbency will make it difficult to exteriorize the uterus. However, it may be difficult to maintain the cow at such an angle without additional assistance. The incision is started 5-7cm cranial to the umbilicus and is extended caudally as far as needed. This approach is not desirable in a heavily lactating dairy animal because the length of the incision is limited by the presence of the udder[3]. Paramedian
The approach is similar to that of the ventral midline, except that the incision is made midway between ventral midline and the subcutaneous abdominal vein. It has the same advantages and disadvantages as a ventral midline, with the added disadvantage of a 3 layer abdominal closure vs 1 layer[4]. Left oblique
This technique has been described by Parish et al. It differs from the standard left paralumbar fossa approach in that the incision begins 10cm cranial to and 10 cm ventral to the cranial-most aspect of the tuber coxae. It is extended cranioventrally at a 45 degree angle and ends 3cm caudal to the last rib. The external abdominal oblique is sharply incised in the direction of the incision. A grid incision is made through the internal abdominal oblique and transverse abdominus muscles, or alternatively, the transverse abdominus muscle is sharply incised in the direction of the incision. The uterus is excised and incised in the manner previously described for a left paralumbar fossa approach. This approach has the same advantages and disadvantages of other

flank approaches, with the added advantage that the uterus is easier to exteriorize. This may benefit surgeons of smaller stature or inexperience, and in cases where peritonitis is of paramount concern such as with an emphasematous fetus[5].
References
1. Barkema HW, Schukken YH, Guard CL, Brand A, van der Weyden GC. Fertility, Production and Culling Following Cesarean Section in Dairy Cattle. Theriogenology 1992: 38: 589-599.
2. Newman KD, Anderson DE. Cesarean Section in Cows. Vet Clin Food Anim 2005: 21: 73-100.
3. Campbell ME, Fubini SL. Indications and Surgical Approaches for Cesarean Section in Cattle. Compend Cont Educ 1990: 12: 285-91.
4. Shultz LG, Tyler JW, Moll HD, Constantinescu GM. Surgical Approaches for Cesarean Section in Cattle. Can Vet J 2008 49: 565-568
5. Parish SM, Tyler JW, Ginsky JV. Left Oblique Celiotomy Approach for Cesarean Section in Standing Cows. JAVMA 1995: 207: 751-752.