all about caesarean section

1. CAESAREAN SECTIONAND
OVARIOHYSTERECTOMY
GEORGE MATHEW
21-MVP-15
Dept. of ARGO
VGO- 503
VETERINARY OBSTETRICS

2. INDICATIONS
RESOLUTION OF EXISTING DYSTOCIA
◦ Fetopelvic disproportion misalliance, post maturity
◦ Fetal maldisposition uncorrected by manipulation
◦ Irreducible uterine torsion
◦ Incomplete dilatation of cervix
◦ Fetal monsters
◦ Uterine rupture
◦ Damaged and severe vaginal prolapse

3. ELECTIVE CAESAREAN SECTION
◦ Surgical termination of prolonged gestation
◦ Avoid existing or suspected fetopelvic disproportion
◦ Termination of pregnancy Life threatening disease in dam

4. PREPARATION FOR SURGERY
◦ Obstetrician should ensure
everything necessary to surgery is to hand
patient well prepared
good facilities and trained assistants
equipments

5. Sterile drapes
Solutions for
surgical
preparations
Sterlized
calving ropes
and chains
Surgical kit
Suture
materials
Medications

6. CATTLE
SURGICAL APPROACH -- CAESAREAN SECTION
◦ Standing left paralumbar celiotomy
◦ Standing right paralumbar celiotomy
◦ Recumbent left paralumbar celiotomy
◦ Recumbent right paralumbar celiotomy
◦ Recumbent ventral midline celiotomy
◦ Recumbent ventral paramedian celiotomy
◦ Left Ventrolateral oblique celiotomy
◦ Left lower flank oblique celiotomy

7. ANAESTHESIA
◦ 1) EPIDURAL ANAESTHESIA
◦ a) Segmental epidural anaesthesia ( Arthur technique)
Between L1 & L2 or Between T13 and L1
b) High epidural anaesthesia
Between L6 and S1
c) Low/ Caudal
Sacro coccygeal or intercoccygeal
coccygeal and posterior sacral nerves are affected

8. ◦ 2) PARAVERTEBRAL ANAESTHESIA
a) Proximal ( Farquharson, Hall, Cambridge technique)
Last thoracic ( T13), first two lumbar ( L1 and L2 ) spinal nerves are approached
from the dorsal aspect of the transverse process of lumbar vertebrae
b) Distal (Magda, Cakala or Cornell technique)
L1, L2 and L4 spinal nerves are anaesthetised
3) INFILTRATION ANAESTHESIA
a) Line block
b) Inverted L or 7 block

9. Standing left oblique
celiotomy
Paramedian celiotomy

10. Standing left paralumbar
celiotomy
(1)Recumbent ventral midline
celiotomy (2) Recumbent ventral
paramedial celiotomy

11. SURGICAL TECHNIQUE
Entry in to the peritoneal cavity
◦ SKIN INCISION
◦ MUSCLE LAYERS
◦ PERITONEUM
External oblique muscle- thicker
Internal oblique muscle
Transverse abdominis muscle

12. A) Epidural
B) LEFT PARALUMBAR-
Local infiltration
C) Paravertebral anaesthesia
Incising external oblique
muscle

14. ◦ LOCATING OF THE UTERUS
Lies caudal and below to the rumen
Foetus normally readily palpable within the uterus
Foetal parts should be identified
Hind limbs in
anterior
presentation
Fore limbs in
posterior presentation

15. ◦ OPENING OF THE UTERUS
Foetal extremity is grasped, for bringing the uterus up
Opening over the fetal extremity Greater curvature of pregnant
uterine horn
Incision– approx. 20 cm long
Follow the direction of longitudinal muscles
Avoid cotyledons
Towards the ovarian end of uterine horn
Be careful, not to cut the foetus accidently

16. Drape should be properly used to covering the sides of uterus
Spillage of uterine fluid in to peritoneum Peritonitis
If difficulty in exteriorizing the uterus insitu incision within abdomen
Embryotomy knife preffered

17. REMOVAL OF FOETUS
◦ CALF IN ANTERIOR POSITION
◦ Caudal end first removed
◦ First hindleg to be retrieved is held, second hindleg is located within uterus
◦ Size of uterine incision should be checked
◦ If length of incision is less- extend to the direction away from the cervix
◦ If impacted in the maternal pelvis, one
should repel pervaginum in to uterus

18. ◦ Traction to the hindlimbs, first dorsally and laterally from laparotomy wound
Caudally towards hindquarters of cow
Special care, not to tear the uterus

19. CALF IN POSTERIOR POSITION
◦ Removed as cranial end first
◦ The first foreleg is located is held and second foreleg are located and brought
to the laparotomy incision
◦ Limbs are passed to assistant for
application of traction
◦ Obstetrician guides the head
◦ Traction applied to calf in lateral and
then in caudal direction

20. ◦ RESUSCITATION OF THE CALF
Remove mucus from fetal mouth, larynx, pharynx
By holding calf upside down, by suction or by shaking gently by
slapping chest
Check the
heartbeat,
respiration,
reflexes.
If no spontaneous
respiration-pinching
foetal nose, tickling of
foetal nasal mucosa
Respiratory stimulant-
Doxapram( 40-100mg)
IV
If respiration still fails to
start, but cardiac
function is present upper
chest wall is raised and
lowered- negative intra
thoracic pressure
Intubation- positive
pressure

21. ◦ MANAGEMENT OF PLACENTA
◦ REPAIR OF UTERINE INCISION
Absorbable suture material
Cushing’s followed Lembert’s
Commencing at the cervical end of uterus
Blood, debris etc. should be removed gently from surface
if not- adhesions
If readily separatable- then separate

22. ◦ Peritoneal cavity lavaged – 5 litres of warm normal saline
◦ Removed by suction before closure of abdomen
If uterine involution is poor 20 IU oxytocin IM
Unnecessary use Strong uterine contractions Loosening of uterine
sutures

23. CLOSURE OF LAPARATOMY INCISION
Peritoneum and transverse abdominis muscle
Internal oblique muscle
External oblique muscle
Subcutaneous and skin

24. COMPLICATIONS
peritonitis
Uterine
Prolapse
Seroma
formation
Subcutaneous
emphysema
RFM
Metritis
Infertility
Sudden
death
Wound
breakdown

25. MARE
◦ INDICATIONS
◦ Fractured pelvis-- Elective CS
◦ Foetal malpresentation– Transverse presentation
◦ Foal in ‘Dog sitting posture’
◦ Malpresentation in small ponies and miniature horses
◦ Torsion of uterus
◦ Foetal monsters

26. ◦ MIDLINE LAPAROTOMY is generally accepted
◦ Skilled anaesthetic and surgical assistance required
SURGICAL TECHNIQUE
SKIN INCISION AND OPENING OF ABDOMEN
◦ Midline incision just caudal to the umbilicus, extending
approx. 30 cm back towards the udder
◦ Skin and subcutis may be oedematous during late pregnancy
◦ Gravid uterus is fragile- optimum care needed

27. ◦ REMOVAL OF FOETUS
Held close to the mare, so that umbilical cord is not ruptured until 5 minutes
after the establishment of foetal respiration
If possible, remove the placenta
CLOSURE OF UTERUS
Large bleeding vessels– clamped
Before uterine closure– edges of uterine incision –sutured
Blood clots remaining are removed
Peritoneal cavity lavaged

28. POST OPERATIVE MANAGEMENT OF MARE AND
FOAL
◦ Foal should be kept dried and warm
◦ Navel management is done
◦ Colostrum intake is monitered
◦ Mare- light laxative diet, regular and limited
exercise for few days
◦ Post operative medical management
◦ Tetanus prophylaxis- for both dam and foal if there is any doubt in mare’s
vaccination staus and foal’s colostrum uptake

29. EWE
INDICATIONS
◦ Incomplete dilatation of cervix
◦ Fetopelvic disproportion
◦ Foetal maldisposition
◦ Severe vaginal prolapse with traumatic damage
◦ In some cases of pregnancy toxaemia- Elective CS

30. ◦ SURGICAL SITE
1)LEFT FLANK APPROACH- Most commonly followed
◦ 2) VENTROLATERAL APPROACH A) Flank laparotomy site
B) Ventrolateral laparotomy site
Advantages Disadvantages
Little risk of damage to incision
by feeding lambs, decreased
contamination
Excessive clipping of fleece is
required
Helaing of wound readily
observed
Full rumen may obstruct access to
uterus

31. ◦ RESTRAINT AND SEDATION
Xylazine @ 0.05-0.1mg/kg body weight IM
Diazepam @ 0.1-0.2 mg/kg
ANAESTHESIA
Lignocaine as local infiltration, paravertebral or inverted L block
Epidural is give to prevent straining during surgery
SURGICAL TECHNIQUE
The skin incision and opening the flank
Locating and opening the uterus
Removing fetuses from the second horn
Repairing and closing of different tissue layers

32. DOE

33. SOW
◦ INDICATIONS
◦ Foetopelvic disproportion- numerically small litter
Previous fracture with healing exostoses
◦ Uterine inertia- not responding to ecbolic therapy
◦ Obstruction of birth canal
◦ Severe vaginal prolapse
◦ Damage to birth canal
◦ Elective CS – in production of gnotobiotic piglets

34. ◦ ANAESTHESIA
◦ Induction by thiopentone and maintenance by isoflurane
◦ 10—15 mL 2% lidocaine (lignocaine) is injected into the lumbosacral space.
◦ SURGICAL TECHNIQUE
◦ A skin incision approx. 20 cm horizontally in the flank
about 5 cm above the lateral edge of the udder
◦ Alternatively, a vertical incision higher up in the flank
◦ The muscles of the flank wall are split carefully

35. ◦ A layer of dense fat immediately outside the peritoneum and this should be
separated carefully
◦ Lift the peritoneum from the underlying viscera before opening the abdomen.
◦ Bifurcation of the uterine horns is located and the nearest horn is gently pulled
out of the laparotomy wound
◦ Longitudinal incision is made in the horn near the bifurcation and the first
piglet is removed.
◦ Piglets are brought back to the uterine wound by reaching inside the horn or
by squeezing the uterus externally to push each piglet back to the wound.
◦ Continuous Lembert suture pattern with absorbable suture.

36. ◦Before closing the uterus the obstetrician must examine the uterine body and the
vagina via the uterine incision to ensure that no piglets are present.
◦The whole length of each horn from ovary to bifurcation must also be palpated
before closure to ensure that it is empty.
◦After closure the uterus is gently wiped to remove any blood before repairing the
laparotomy incision.
◦The muscle layers are repaired in turn with an absorbable suture, avoid trapping
fat between the sutures. The skin is repaired with braided nylon.

37. DOGS AND CATS
◦ INDICATIONS
◦ Uterine inertia that fails to respond to ecbolic therapy.
◦ Fetopelvic disproportion failing to respond to other treatment methods.
Obstruction of the birth canal.
◦ Fetal malpresentation that cannot be corrected.
◦ Evidence that fetal life is becoming compromised.
◦ Elective caesarean

38. PROGNOSIS
◦ Relation between 2 nd stage labour and surgery
Before 6 hours- Good for bitch and pups, placental separation
may occur in first puppy
6- 12 hours - Good for bitch and pups, first pups are unlikely to survive
12-24 hours - Good for bitch, some pups may be dead
24-36 hours - Fair to good for bitch,
poor for most pups
36+ hours - Guarded for bitch,
very poor for pups

40. ANAESTHETIC CONSIDERATIONS
◦ IDEAL ANAESTHETIC PROTOCOL
◦ Ample analgesia, muscle relaxation, sedation
◦ Without endangering mother and foetus
◦ Physiochemical properties that allows drugs to cross the blood- brain barrier
also enable their placental transfer
premedication- Butarphanol @ o.2 mg/kg, Atropine @ 0.045 mg/kg IM or IV
Induction - Propofol @ 3mg/kg+ ketamine @ 3mg/kg as IV up to effect
Maintenance - Isoflurane 2.5%

41. ◦ A) Implications of physiologic alteration
◦ B) Perinatal pharmacology
◦ C) Placental transfer
Q/t = KA (Cm –Cf) Q/t = Amount of diffused substance per unit time
D K = Diffusion constant of a given substance
A = Surface area available for diffusion
Cm = Conc. Of substance in maternal blood perfusing the placenta
Cf = Conc. Of substance in foetal blood perfusing placenta
D = Thickness of placental membrane
D) Maternal and foetal drug concentration
E) Drug selection
FICK EQUATION

43. FEMALE REPRODUCTIVE ANATOMY- CANINE

44. OHE- Procedures

47. Early-Age Gonadectomy Expectations
◦ • Early gonadectomy is safe in dogs and cats >12 weeks of age
◦ Female dogs are at greater risk of urinary incontinence if ovariohysterectomy
is performed before 3 months of age
◦ • Growth plate closure is delayed by 8 to 9 weeks, resulting in increased long
bone length
◦ • Increased risk for excessive tibial plateau angle in large-breed dogs
◦ • Penis, prepuce, and vulva may appear small and infantile if neutered at 6 to 8
weeks
◦ • Associated with lower morbidity and quicker anesthetic recovery

48. Technical variations of OHE
◦ Flank and laparoscopic methods
◦ use of stapling equipment, ultrasonic scalpel, vessel-sealing devices, transfixation
ligatures, Miller’s knots practiced
Left flank method
Laparoscopic method

49. Skin stapler Ultrasonic scalpel Vessel sealing
device

50. Transfixation sutures
Miller’s knot to occlude the ovarian
pedicles

51. Appearance of a large ovarian
cystadenocarcinoma
Ovarian cysts identified during an
elective ovariohysterectomy.

52. OHE for Dystocia
◦ En bloc resection
◦ OHE of the gravid uterus by first exteriorizing and isolating the ovarian
pedicles and separating the broad ligament from the uterus to the point of the
cervix.
◦ Manipulate fetuses in the vagina or cervix into the uterine body.
◦ Double or triple clamp the ovarian pedicles and uterus just cranial to the
cervix.
◦ Quickly transect between clamps and remove the ovaries and uterus.

53. Give the uterus to a team of assistants to open and resuscitate the neonates
The time from clamping the uterus to removal of the neonates should be less than
60 seconds.
Double ligate ovarian and uterine pedicles.
Inspect for hemorrhage and close the abdomen

54. ADVANTAGES DISADVANTAGES
Future population control, no need of further surgeries More chances of bleeding
Reduce intraoperative peritoneal contamination If not properly done risk to
life of foetus
Scanty or nil postoperative lochial discharge
Owner’s who can’t afford a second operation for sterlization

55. ADVANTAGES
◦ Treatment of choice of most uterine diseases
◦ PYOMETRA
◦ UTERINE TORSION
◦ LOCALIZED AND DIFFUSE CYSTIC ENDOMETRIAL HYPERPLASIA
◦ UTERINE RUPTURE
◦ UTERINE NEOPLASIA
◦ MAMMARY NEOPLASIA
◦ DIABETIC AND EPILEPTIC PATIENTS

56. POTENTIAL COMPLICATIONS
◦ Stump pyometra
Pain
Hemorrhage
Infection
Dehiscence, Adhesions
Urinary incontinence
Ovarian remnant syndrome
Ureteral ligation
Fistula

57. REFERENCE
◦ .
◦ Fossum, T.W., 2018. Small Animal Surgery E-Book. Elsevier Health Sciences.
◦ Jackson, P.G., 1995. Handbook of veterinary obstetrics. WB Saunders
◦ Noakes, D.E., Parkinson, T.J. and England, G.C., 2018. Arthur's Veterinary Reproduction and
Obstetrics-E-Book. Elsevier Health Sciences.
◦ Roberts, S.J., 1986. Veterinary obstetrics and genital diseases (Theriogenology).

58. ◦ THANK YOU