Bovine Dystocia

Firstly, a big welcome to all our #vetfinals newbies, both from Nottingham and abroad (mainly the RVC…) Keep spreading the #vetfinals love!

So, to kick off, Wendela introduced the first case:

Let’s get straight in there with some questions:

NB/ this was an autocorrect fail and was meant to say lactations… But still all good questioning, to which Wendela replied:

Now we need a plan. Luckily, there is a crack team of revisionees on hand to sort out the problem:

Now, what with Schmallenberg about this year, I’m sure this is possible, but I think we should pop this right at the bottom of our differentials list (although it did earn a cheeky lol from Liz):

Let’s decide what we need to have in our car ready for a visit:

So, we’re on our way to the farm – what next?

Excellent noting of some health and safety from Bryn with use of the hands free and directions from Roxanne! This enables us to make it to the farm in one piece, so what are our next steps?

Summary: initial approach to a dystocia case

Systematic approach!

1. History
2. General examination
3. Vaginal examination

History

Age / parity?

Full term /premature?

Breeding history?

General management during pregnancy?

When did straining start?

Has a waterbag appeared, and if so when first seen?

Has there been escape of fluids?

Have parts of fetus appeared in the vulva?

Has examination been performed or assistance been attempted? If so what has been done?

Is the animal still eating?

General clinical examination

General physical condition – quick!

Recumbent? Exhausted?

TPR, mucous membranes
Appearance of vulva
– White – internal bleeding
– Swelling
– Bruising from previous manipulations
Would a caesarean be a
possibility?

Now onto the next step, our vaginal examination:

So we know what we want to do to our cow, now how are we going to go about it?

So we need to get a halter on her and keep our fingers crossed she’s a nice quiet cow. If not however, we do have some more tricks up our sleeve:

So xylazine it is for sedating our cow if needed, check out the data sheet here:
 http://www.noahcompendium.co.uk/Bayer_plc/Rompun_2_ACU-_w_v_Solution_for_Injection/-23627.html 

And if you needed any more convincing about the need for adequate restraint:

Now we have our cow nicely restrained, we can get on with our examination:

First things first, try and identify the legs in question:

Then there are lots of other fab suggestions of things we need to be on the lookout for:

http://twitter.com/ClaireVRoberts/status/327509797148712960

Summary: vaginal examination in a dystocia case
As noted by Claire, there is a lovely step-by-step protocol for a vaginal exam in our y4 repro notes, for those of you non-Nottinghamites or if you just don’t feel like trawling your notes, here they are again:

Preparation
Ensure adequate restraint, with sedation if necessary
Clean environment and non-slip floor surface
Wash hands and arms and wear gloves
Clean external genitalia
LUBE. You can never have enough lube.

1. Injury/abnormalities of the birth canal
Note these and inform the farmer of these BEFORE you start

2. Position of uterus, umbilical cord and foetus

Torsion – vagina
‘ends’ abruptly at the pelvic brim, mucosa drawn into tight spiral folds,
confirm on rectal

Position of umbilical
cord, replace if necessary

PPP of fetus – presentation, position and posture
– Presentation: relation between longitudinal axis of foetus and maternal birth canal (longitudinal or transverse), further described by which part of the foetus is entering the birth canal first (cranial, caudal, dorsal, ventral)
– Position: the surface of the birth canal to which the vertebral column of the foetus is apposed (dorsal, ventral, left lateral, right lateral)
– Posture: disposition of the moveable appendages of the foetus, including the flexion and extension of neck and limb joints
The ideal PPP is cranial longitudinal presentation, dorsal position, extended posture
Try and identify twins, if present

3. Signs of a live foetus

Limb withdrawal –
pinch between claws

Suck reflex –
swallow when place base of tongue

Corneal/palpebral reflex –
fibrillation of eyeball when touched

Pulse in umbilical cord
(posterior presentation)
Ictus cordis – apex beat of
heart at IC 3-5 (anterior presentation)

Dead 6-12h – no emphysema but
cornea is cloudy and grey
Dead for >24h – fetal
emphysema and detachment of hair, smell

4. Dilation of cervix

Active dilation occurs during the 1st stage of parturition (relaxin and oestrogen)
Passive dilation in the 2nd stage (uterine contractions and increased pressure in birth canal)
Cervix should feel soft and smooth
May be able to cause some dilation manually
Check for hypocalcaemia – will cause uterine atony

5. Relative size of foetus

Widest point of
fetus: greater trochanter of the femur and greater tubercles of the humerus

6. Dilation of vagina and vulva
Assess manually and stretch more if necessary

So, time for our next Wendela update:

But we’re not sure about calf viability:

So we have a live calf still! Now lets finish the rest of our vaginal examination:

What to do now?

Despite our best efforts at retropulsion, we still have an issue:

How are we going to try and reduce straining to allow for manipulation?

Option 1: Clenbuterol (Planipart)

Option 2: Epidural

So, for our epidural, what drug do we want to use? Let’s kick off the discussion…

So procaine (Willcain) is the correct option under the cascade! Another quick side note:

We also need to be careful when it comes to working out a dose rate:

And here is a handy guide to epidurals in the cow, courtesy of Louisa Graham 🙂

Now we’ve got an epidural in and we’re all in agreement about some retropulsion, then what?

http://twitter.com/svybvm/status/327512525350502400

http://twitter.com/MO05EE/status/327512143584976896

At this point, we also need to consider some sizing issues:

Summary: will it fit??

Guidelines for extraction (anterior presentation)

Try and get a head and feet ropes/chains on, and direct the head of the fetus into the birth canal, past the pelvic entry
Assess the space between the calf’s head and the ventral aspect of the dams sacrum – if the head is squeezed tightly then it is unlikely the rest of the calf will fit

In the standing animal:
– Apply traction of one strong person
– Palpate the greater tubercles of the humerus
– If the tubercles are <10cm cranial of the pelvic entry, you will be able to extract the calf
– Care with crossed legs or plantar side of feet facing each other – this will increase the width of the calf when in the pelvis
– Beef calves: beware the heavily muscled hind legs and pelvis, and muscling around the front end causing rotation of the forelegs
– If you can get the head into the pelvis with space between the head and sacrum, you should be able to deliver the calf with traction and patience

In the recumbent animal:
– Similar to the standing approach
– Measurement is tubercles <5cm cranial of the pelvic entry

To deliver the calf
– Pull slightly down to try and avoid injury to the dorsal aspect of the vagina
– May need to rotate the calf so it fits better – maternal pelvis is widest on an angle
– Extend the front legs – do not pull the calf when it’s elbows are flexed
– Chain or rope placement below the fetlock (possibly with a loop above as well, although never just a loop above the fetlock!)

Guidelines for extraction (posterior presentation)
Better assessed in
the recumbent animal, may be easier to deliver in lateral recumbency

Confirm pelvis of calf
is at 90 degree angle with pelvis of the dam

Pull towards the
tail of dam with 2 persons’ strength, pulling up (pulling down with a jack risks fracture of the legs)

If you can visualise
the tarsi outside the vulva you can extract (otherwise greater trochanters are not
in the pelvis)

The soft tissues of the birth
canal often need dilation before extracting the calf – they are not getting the appropriate
signals from the calf
so require manual stretching

Beware of the umbilical cord – squashed in the pelvis so leading to hypoxia of the foetus, need to be quick!

All of this is done to ensure there is no foetal-maternal size disposition that is going to result in hiplock – once you make the decision to pull then get stuck, there is no going back!

Luckily, there are no complications and we get a good result (the second in two weeks, what’s going on here?!)

Suggestions please:

Lots of TLC as well for the poor girl! It’s been a tough evening.

Now, for a worst case scenario question:

I do believe that this is the aforementioned In Practice article:  http://inpractice.bmj.com/content/28/8/470.full.pdf+html?sid=4d2c0e9b-28c1-4eab-aeda-04b9af0a78ff 

Luckily this isn’t the case!

We’ve mentioned tubing the calf with colostrum but…

So we would like to get the calf to suckle, releasing lots of lovely oxytocin. Let’s discuss oxytocin a bit further- should we supplement?

So, if we’d needed to use clenbuterol (Planipart) at some point, it would be advisable to give her a dose of oxytocin after calving. However, we only used an epidural in this case, so oxytocin is probably not required, as long as we can get the calf sucking well.

There was a cheeky last minute intervention from Chris Hudson, with an excellent point about analgesia: