Dystocia due to faulty position, presentation and posture and their correction

Dr. Muhammad Afzal Ansari
m.afzal8817@gmail.com
Dystocia due to faulty position, presentation and Posture and their
correction
Manoeuvres used to correct Position, Presentation and Postural Defects:
The mechanics of the correction of position, presentation and postural defects are extremely
simple; the secret of success lies in an appreciation of the value of retropulsion. The manoeuvres
that are practised on the foetus in correction of defects are described below:
Retropulsion: means pushing the foetus into the uterus from the maternal birth canal. This action
is essential to find out defects in presentation, position and posture. It can be done by applying
pressure with the hand or using the crutch repeller, on the presenting part of the foetal body.
Extension: Means the extension of the flexed joints when there are postural defects. The flexed
joints can be extended with hand or using snare (rope).
Traction: Is the application of force to the presenting parts of the foetal body, to help the dam in
expulsion of foetus. This can be done using snare or hooks.
Rotation: is the technique of alteration of the position of a foetus by moving it around its
longitudinal axis so as to bring into the normal position.
POSITION
It is the relationship between vertebral column of foetus with the four quadrants of pelvic inlet of
the dam. Faulty position of the fetus is encountered more frequently in horses than in cattle. This
is considered to be due to the fact that, in late gestation or first-stage labour in horses (but not in
cattle), a physiological rotation of the fetus from the ventral to the dorsal position occurs, and
occasionally this fails. The fetus then presents longitudinally usually anteriorly, but sometimes
posteriorly either with its vertebral column applied to one side of the uterus (right or left lateral
position) or facing the floor of the birth canal (ventral position). The process whereby the bovine
or ovine fetus sometimes comes to lie in ventral position is not understood. It is hardly likely to be
a gestational position; more probably it arises during the first stage of labour, when the uterine
peristaltic force generates a vigorous reflex response in the fetus that causes it to rotate about its
longitudinal axis.
Anterior presentation, lateral position (Dorso iliac):
In the case of a live calf or foal, the obstetrician passes his or her hand to the fetal head and, by
means of the thumb and middle finger, presses on the fetal eyeballs, the latter being protected by
the eyelids. Firm pressure causes a convulsive reflex response in the fetus and, by applying a
rotational force in the appropriate direction, it is easy to turn the fetus into the dorsal position. The
fetal nose and forelimbs are then advanced into the maternal pelvis, and the maternal expulsive
efforts assisted by gently pulling on these appendages. If this method fail, then snares are attached
to the limbs and possibly caudal epidural anesthesia is induced; rotation is performed
mechanically, firstly by repelling it as far cranially as possible, crossing the snares in the
appropriate direction, and then by applying traction. This will tend to result in the snares becoming
more or less parallel, which can only occur if the fetus rotates about its longitudinal axis. It is
important to ensure that the snares are crossed in the right direction so that rotation of the fetus is
not increased. Unless the degree of faulty disposition is only modest, the procedure will require to
be repeated many times before the defect is fully corrected, and birth can be completed by traction.

For such a procedure to be effective, it is critical that there should be plenty of fetal fluid
supplementation.
Anterior presentation, ventral position (Dorso pubic):
The same two methods, namely using the hand with eyeball pressure with manual rotation or
mechanical rotation by applying traction to crossed snares, as described for the correction of a
lateral position defect, can be used, although the procedures will usually need to be repeated
several times. Placing the dam in dorsal recumbency with the hindquarters raised will facilitate the
procedure. If the calf or foal should rest on its back with the head and limbs flexed on to its neck
and thorax, the fetus must first be repelled so that the head and forelimbs can be extended. Rotation
is then carried out.
Posterior presentation, lateral position:
The operator introduces a hand and grasps the stifle region of the upper limb. Simultaneous
retropulsion and downward pressure are applied to rotate the fetus through 900
.
Posterior presentation, ventral position:
The operator introduces a hand between the fetal hindlimbs and up to the inguinal region, where
one of the thighs is grasped; then, pushing forwards, the operator rotates the fetus through a half
circle. Failing this, traction on crossed limb snares should be used. An alternative procedure is to
place a traction bar between the projecting hindfeet and to bind it to them by means of a snare;
rotational force is then applied to the traction bar.

There is a grave risk that the hind feet of a foal in posterior presentation, ventral position, will
penetrate the vagina and rectum. In such a case a caesarean operation should be performed and the
rectovaginal fistula repaired later.
PRESENTATION
It is relationship between longitudinal axis of dam with the longitudinal axis of foetus and parts
present towards birth canal. The presentation may be divided into three parts:
(i) Longitudinal presentation (normal).
(ii) Transverse presentation (abnormal).
(iii) Vertical presentation (abnormal).
Instead of the long axis of the fetus being in line with the birth canal it may be disposed vertically
or transversely to the pelvic inlet. Owing to limitation of space in the sagittal plane, absolute
vertical presentation is not possible but oblique vertical presentation occurs rarely, in mares rather
than cows. According to whether the fetal vertebral column or abdomen is presented at the pelvic
inlet, such dystocias are described as dorsovertical or ventrovertical presentations. Transverse
presentations are also uncommon and are more likely to be encountered in the mare; they may be
ventrotransverse or dorsotransverse and, again, oblique variants are more often seen.
All dystocias that arise from defects of presentation are serious, the special form of bicornual
transverse presentation of the mare being notorious. The aim in all cases is to achieve version of
the fetus so that a vertical or transverse presentation is converted into a longitudinal one. Obviously
the nearer extremity should be moved towards the pelvic inlet, but where both extremities are
equally distant it is usually simpler to convert to posterior presentation (two appendages being
manipulated rather than three).
Transverse presentation:
When longitudinal axis of foetus forms a right angle with the long axis of dam in transverse plane,
the presentationis is called as transverse presentation. It is of three types:
Dorso-transverse or dorso-lumbar:
Longitudinal axis of foetus forms a right angle with the long axis of dam in transverse plane and
dorsum (vertebral column) of the foetus becomes convex and faces the pelvic inlet, the condition

is called dorso-transverse presentation or when foetus is in transverse presentation and its dorsum
faces the pelvic inlet, the presentation is called dorso-transverse presentation. This is a rare cause
of dystocia, but oblique variants of it occur in both the mare and cow.
Correction:
The obstetrician should ascertain the polarity of the fetus and decide which extremity is nearer the
pelvic inlet. The technique of correction required involves repulsion of the fetus, and the
advancement of its nearer extremity to the birth canal. Unless one extremity is within easy reach,
uterine version is likely to be an extremely difficult or impossible task in both the cow and mare.
If there appears to be a chance of success, the cow should be given an epidural anaesthetic, and in
the mare general anaesthesia should be induced, so that she can be placed on her back. Fetal fluid
supplement is then instilled and an attempt made by manipulation of the proximal fetal extremity
to turn the fetus into ventral position, anterior or posterior presentation. The next step is to rotate
the fetus into dorsal position. Finally, it is delivered by traction. If after a short determined effort
it is obvious that version cannot be achieved, a caesarean operation should be performed
immediately. Fetotomy is very difficult to carry out in this type of dystocia and consequently is
not recommended.
Ventro-transverse or Sterno-abdominal:
When foetus is in transverse presentation and its ventral or sterno-abdominal surface faces the
pelvic inlet, the presentation is called ventro transverse presentation. This presentation is more
likely to be seen in the mare than in the cow, and oblique variants of it are more usual. A variable
number of fetal appendages may enter the maternal pelvis. It is possible that the head as well as
the forelimbs are in the vagina, but it is usual for two or more legs only to be presented. The
condition must be distinguished from twins and double monsters and from schistosoma reflexus.

Correction:
The aim of vaginal interference is firstly to convert the abnormality into longitudinal– usually
posterior – presentation, ventral position; this means that the posterior extremity must be advanced
while the anterior extremity is repelled. General anaesthesia and dorsal recumbency are helpful in
the mare. Unless progress with version is soon apparent, the caesarean operation is recommended
for both mare and cow.
In the bicornual type of transverse presentation peculiar to mares the fetal extremities are disposed
in the two horns and its trunk lies across the anterior portion of the uterine body. Ventral
displacement of the uterus may have occurred, and, if so, it may be impossible to palpate the fetus.
As soon as the presentation is recognized a caesarean operation should be performed.
Vertical Presentation:
When longitudinal axis of foetus forms the right angle with long axis of dam in vertical plane, the
presentation is called vertical presentation. It is of three types:
Oblique dorsovertical presentation:
When foetus is in vertical presentation and its dorsum (i.e. vertebral column) faces pelvic inlet, the
presentation is called dorso-vertical presentation.

Correction:
According to whether the head or breech is nearer the pelvic inlet, the presentation is converted
into anterior or posterior longitudinal. An attempt is made to bring the fetal extremity (head or
limbs) to the pelvic inlet, and firstly to convert the defect into a ventral longitudinal presentation.
The fetus can then be rotated to the dorsal position as described earlier. Retropulsion and the
presence of copious fluid (natural or artificial) in the uterus are both essential. A grip is taken on
the fetus by means of Krey’s hook as near as possible to the more proximal fetal extremity. Then,
while retropulsion is applied, the hook is pulled on with a view to bringing the fore or hind end of
the fetus to the pelvic inlet. After adjustments of position and posture, the fetus is then delivered
by gentle traction. If version is not practicable, a caesarean operation should be performed.
Oblique ventrovertical presentation:
When foetus is in vertical presentation and its ventral portion i.e. sternum and abdomen faces
pelvic inlet, the presentation is known as ventro-vertical presentation. It is still rare and is only
likely to be encountered in the mare. However, when present it should cause no difficulty in
diagnosis; if the veterinary surgeon is called to a foaling mare from which the fetal head and
forelimbs protrude, and to which lay traction has been applied without success.
Correction:
Most cases are severely impacted, but after the induction of epidural anaesthesia and the infusion
of lubricant fluid into the uterus, an attempt should always be made to repel the fetus sufficiently
to allow the hindfeet to be pushed off the pelvic brim into the uterus and thus to convert the dystocia
into a simple anterior presentation. Traction is then applied. Placing the mare or cow in dorsal
recumbency with the hindquarters elevated often helps. If this attempt fail, then a caesarian
operation is the only effective method of treatment.
POSTURE
It is relationship between movable appendages of foetus (head, neck, or limbs) to its own body.
Postural defects refers to the disposition of the movable appendages of the foetus. The movable
appendages may be flexed, extended, or retained (usually referring to the head). Retention can be
to the right, to the left, or above or below the fetus. The primary reason is postural abnormalities
of the long fetal extremities. Extraction of a fetus in an abnormal posture or position should not be
attempted until the abnormality is corrected because of the increased probability of laceration.
Postural defects in anterior longitudinal Presentation:
Fore limb flexion:

Carpal flexion: Unilateral or bilateral.
Shoulder flexion: Unilateral or bilateral.
Flexion of head & neck:
Downward deviation.
Lateral deviation: Left or right.
Postural defects in posterior longitudinal presentation.
Hind limb flexion:
Hip flexion: Unilateral or bilateral.
Hock flexion: Unilateral or bilateral.
Postural Defects in anterior longitudinal Presentation:
Carpal flexion:
Unilateral or bilateral carpal flexion can be responsible for dystocia in cattle. If the flexed carpus
along with the fetal head is within the maternal pelvis, the situation is described as engaged carpal
flexion, whereas if the flexed carpus is cranial to the maternal pelvis it is described as disengaged
carpal flexion.
Correction:
Correction requires that the fetus and the flexed limb be repelled cranially out of the pelvis to
increase the space available for correction. The operator introduces the hand corresponding to the
side of the displacement into the birth canal and grasps the metacarpus immediately proximal to
the fetlock. Then the limb is lifted dorsally and the shoulder and elbow joints are flexed. When the
fetlock is above the pubis, the hoof is cupped in the hand and pulled into the pelvis. If needed,
traction can be applied with a snare placed proximal to the fetlock joint. While lifting and repelling
the carpus with one hand, the operator applies gentle traction to draw the hoof into the pelvis with
the other.

Shoulder flexion:
This condition can be unilateral or bilateral. In bilateral shoulder flexion only foetal head may be
presented at the vulva or in the vagina. In unilateral shoulder flexion head and one of the limbs
may be visible at the vulva while other limb is retained in the abdominal cavity. The figure shows
the unilateral shoulder flexion in calf.
Correction:
Correction is accomplished by grasping the radius and pulling it toward the maternal pelvis.
Shoulder flexion is thus converted to carpal flexion, which is then corrected by the methods
previously described. If a traction snare can be placed distal to the carpal joint, it can be used to
apply extractive force with one hand while the other repels the shoulder joint.

Shoulder-elbow flexion or elbow lock posture:
This is the most common in heifers and results in impaction of the elbow joints on the pelvic brim.
The condition is recognized when the muzzle of the fetus lies directly above the hooves, rather
than in its normal position approximately at the middle of the metacarpus.
Correction:
The malposture is corrected by first repelling the fetal body into the birth canal and then applying
traction to the affected limbs, one at a time, until the elbow and shoulder joints are fully extended.
Foot-nape posture:
Foot-nape posture is not common in cattle but arises when one or both of the forelimbs is displaced
upward to lie on top of the head and neck.
Correction:
The defective posture is corrected by grasping the fetlock of the affected limb and forcing it
downward and laterally while simultaneously lifting and repelling the head with the other hand
until the forelimbs are in their normal position. In protracted cases, continued attempts to deliver
the fetus may force the hoof through the dorsal wall of the vestibule, resulting in the formation of
a fistula or perineal laceration.
Dog sitting Posture:
Dog sitting posture causes dystocia in fetuses presented cranially because of flexion of the
hindlimbs at the hips. The hooves may be impacted against the maternal pelvis or lie in the vagina
alongside the forelimbs. The cranial portion of the fetus is delivered normally, but the impediment
is discovered when delivery cannot be completed. The condition is diagnosed by careful
examination, which may be difficult if the cranial portions of the fetus occupy the pelvic canal.

Correction:
An attempt may be made to correct the malposture by repelling the hindlimbs as deeply as possible
into the uterus. Correction is likely to be successful only when the fetus is small. Delivery by
cesarean section or fetotomy may be preferable in many cases.
Lateral deviation of head:
The head may be displaced to either sides and this is one of the most common types of dystocia in
cow. In cattle, the head most commonly is deviated to the left side of the fetus and lies against the
thoracic wall. When this condition occurs, only the foetal limbs will be presented at the vulva and
per vaginal palpation may reveal absence of the head. Figure shows this condition.
Correction:
Apply snares at the presented limbs and apply retropulsion at the base of the neck. Locate the head
and the malposture is corrected by grasping the orbital grooves with the thumb and middle finger
(forceps grip) and drawing the head into the maternal pelvis. A rope snare placed behind the incisor
teeth may be useful in difficult cases. Traction to redirect the head can be applied with the snare

by the operator or by an assistant while with the other hand the operator guides the head and
protects the uterine wall from the incisor teeth by covering the fetal mouth.
Downward displacement of head:
This is uncommon type of dystocia in cattle and if it occurs the nose of the foetus will be retained
at the pelvic brim and the limbs will be presented at the vulva. In long standing case the head may
be pushed deep into the abdominal cavity. The head may be deviated ventrally between the
forelimbs, with the mandible resting against the sternum. A hasty examination may fail to reveal
the presence of the head, and the malposture may be mistaken for a case of caudal presentation.

Correction:
In some instances, the malposture can be corrected by repelling the fetal forehead with the thumbs
while simultaneously lifting the jaw with the fingers. Correction in more severe cases requires that
one or both forelimbs be repelled and flexed at the carpus, elbow, and shoulder joints. Space is
then available to convert the ventral displacement of the head to lateral displacement, which is
then corrected by drawing the head into the pelvis. The induced malposture of the forelimb is
subsequently corrected after the head is in its proper position. Should attempts to reposition the
head by these methods not be successful, the dam can be sedated, cast, and rolled to dorsal
recumbency. The fetus then falls toward the maternal spine and away from the narrow ventral
portion of the pelvis, allowing the head to be more easily guided into the pelvic canal.
Postural defects in posterior longitudinal presentation
Displacement of the hindlimbs is rarely a problem unless the fetus is in caudal presentation. The
incidence of caudal presentation in cattle can vary depending on management conditions and
genetics, and such displacements frequently are complicated by dystocia. One or both hindlimbs
may be retained and flexed at the hock or at the hip.
Hock Flexion:
The condition is usually bilateral. The points of the hock may be felt in front of the pelvic brim or
may be firmly engaged in the maternal birth canal. The tip of the fetal tail may be seen at vulva
and the flexed hock may be palpable at the pelvic inlet. If only one limb is involved the other leg
can be extended and protruded through the vulva.
Correction:
An estimate will be made of the likely degree of difficulty in correction, and a decision made on
whether epidural anaesthesia and/or fetal fluid replacements will be needed. The aim of the
manipulative procedure is to extend the hock joint(s); the difficulty is in procuring sufficient space
for this to be done. In early cases, with or without epidural anaesthesia, the posture may be
corrected by hand. To correct hock flexion posture, the limb is grasped at the metatarsus and
repelled cranially and laterally until sufficient space is available to draw the hoof in a caudal and
medial direction into the pelvic canal. The operator should cover the hoof with one hand to protect
the uterine wall as it is rotated medially. In some cases, application of a snare distal to the fetlock
joint can facilitate correction. The cord is placed between the digits of the affected hoof, and

traction is applied. The operator then applies opposing forces by repelling the hock while
simultaneously applying traction to the snare. This action results in flexion of the fetlock and
pastern joints while the hoof is drawn toward the pelvic brim.
Hip flexion posture:
When both hindlegs are retained in the uterus, a commoner condition than unilateral retention.
Bilateral hip flexion (colloquially referred to as “true breech” presentation) prevents entry of the
fetus into the cervix; thus, the stimulus for the abdominal press is lacking, and signs of the second
stage of labor may be minimal or absent. Usually on vaginal examination, the calf’s tail is
recognized.The degree of engagement of the fetus in the maternal pelvis varies, and in some cases
the hand cannot be passed to the hocks of the calf. This constitutes one of the most difficult types
of dystocia dealt with by veterinary obstetricians.
Correction:
Hip flexion is corrected by grasping the lateral aspect of the tibia as closely as possible relative to
the hock. The hock and stifle joints are flexed by drawing the hock toward the maternal pelvis.
After the hock and stifle joints are fully flexed, the malposture becomes hock flexion, which
subsequently is corrected as previously described. If manipulative delivery is impossible, cesarean
section or fetotomy may be done.

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