Multiple Cesarean Section Jenny

Multiple Cesarean Section Jenny | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Multiple Cesarean Section Jenny Cheru Telila Feyisa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5035757/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Jenny dystocia occurs very rarely and is mainly associated with postural defects due to long fetal extremities. However, the management of dystocia in equines is relatively difficult compared to that in other large animals. Due to the absence of well-described published papers on cesarean section in donkeys, this condition can be life-threatening after unsuccessful surgical intervention. Patient presentation: A 4-year-old Jenny with a difficult birth due to a previous car accident presented for 3 consecutive years at different stages of labor onset. Up on early presentation, there was straining and frequent aggressive rolling. Further examination also revealed a fully dilated cervix and narrow pelvic cavity due to the downward bending of the iliac wing. Surgical sites (lower flank, ventral midline, and paramedian) were used for each delivery. General anesthesia was used in all three procedures, and local infiltration of 2% lidocaine along with light general anesthesia was used at the time she presented with a live fetus. Surgical sites aseptically prepared for cesarean section and dead fetuses were removed at the 1 st and 3 rd parity due to delayed presentation. However, on the 2 nd parity, a live female foal was delivered. In all the approaches, the 1 st layer of uterine closure was made by using a simple continuous suture pattern (biting all the layers of the uterine wall). Then, the sutures were oversewed with a Cushing suture pattern using #0 polyglycolic acid (PGA). The skin was closed by different suture patterns during each technique using nonabsorbable suture material # 1 silk. Postoperative subcutaneous swelling was observed and regressed gradually in all the approaches. The duration of skin suture removal was determined based on the extent of wound healing and the site of the incision. Conclusion : This is the first ever-identified surgical case in a donkey. Thus, this study was able to indicate different approaches for cesarean section in equines. Moreover, due to the bleeding nature of the equine uterus, simple continuous suturing was the pattern of choice for 1 st layer uterine closure. It was also concluded that subcutaneous edema is unavoidable in donkeys. Large Animal Medicine Cesarean section Dystocia Jenny Pelvic deformity Surgical approaches Figures Figure 1 Figure 2 Figure 3 Background Equine species are long-day seasonal breeders, and their parturition process is very similar to that of other domestic animals in many ways 1 . The length of the pregnancy period is 365 to 376 days, but extreme variations range from 340 to 395 days, and parturition is a rapid and violent feature 2,3 . Foaling is the process of giving birth to a foal and is a prompt and forceful event in equine breeding 4 . During normal foaling, the mare becomes restless, sweats, urinates frequently, contractions begin, and the fetus changes position so that her head and forelimbs are in the birth canal as stage I progresses, which can last between 1 and 4 hours 4,5 . Stage II is the time of fetal delivery, which usually lasts less than 40 minutes. It is characterized by the appearance of a water bag or the commencement of forcible straining, active abdominal contractions, and the appearance of the fetal leg, and mothers may choose to stand or lie down for birth 6 . Delivery of the fetal membranes was considered stage III, and the patient was considered to be in normal condition if it expelled within the first 3 hours after parturition 5 . Dystocia is defined as a difficult birth that reduces neonatal viability, causes maternal injury/death, or requires assistance during delivery 7,8 . However, this procedure is challenging for many equine practitioners 4 . Dystocia in jenny is very rare and estimated to account for 1-4% of foales, and it can be caused by maternal problems such as abnormal pelvic conformation as a result of a previous injury, exhaustion or uterine inertia; infection such as equine herpesvirus, which causes abortion in late pregnancy; or the absence of expulsive forces. The major fetal problems related to dystocia include fetal malposition, size, malformation, and twins 4,9 . Among these abnormalities, malposturing of long fetal extremities is considered the most common cause of dystocia in equines, although positional and presentational abnormalities occur to a lesser extent 6 . Dystocia was declared when the 2 nd stage of parturition exceeded 20 minutes without fetal expulsion during the mare. Thus, fetal mortality and future mare fertility depend on the time and decisions made during foaling 4 . A delay in labor may result in deterioration of fetal health when oxygen delivery decreases as the placenta begins to separate from the uterus. Equine dystocia is regarded as a true emergency because it threatens the dam and fetus 10 . The risks are increased in small donkeys because of the domed large forehead of some foals 3 . The choice of management may depend on the status of the fetus, duration and severity of the dystocia, economic value of the dam and fetus, clinician expertise, client preference, and facilities available. Prompt assessment of the cause of dystocia is important for rapid decision-making concerning the course of action 5 . If a fetus is alive, vaginal delivery may be attempted. However, if a live foal in an abnormal position cannot be repositioned per vagina, a cesarean section should be chosen as soon as possible 11 . An equine cesarean section is an emergency in which a veterinarian should decide on the need for general anesthesia, and the choice is made after considering the safety and comfort of the patient and fetus and the comfort of the surgeon so that the surgery can be completed rapidly 10 . Equine patients have a greater risk of mortality and morbidity related to general anesthesia than other domestic species and humans 12 . Therefore, for cesarean section, local anesthesia is considered a lifesaving procedure in very high-risk patients 10 . The management of dystocia in equines is relatively difficult compared to that in other large animals. Additionally, due to the absence of well-described published papers on cesarean section in donkeys, this procedure has been threatening both the life of the dam and the fetus after unsuccessful manual or surgical intervention. Therefore, the present case report aims to describe different cesarean section approaches and their outcomes in jenny. Case Presentation A 4-year-old local breed jenny weighing approximately 140 kg was used for surgical intervention for dystocia for three consecutive years. Jenny faced a car accident, and her pelvic bone was damaged when she was 2 years of age. At the 1 st parity, signs of labor were noticed during the first 4 hours of labor. However, she became exhausted and lay down ( Figure 1A ) after being manipulated by two different para veterinarians at different times before reporting to a veterinary teaching hospital (VTH). During the 2 nd ( Figure 1B ) and 3 rd parity, she was directly presented to the hospital without any prior intervention. At that time, she was straining, lying down and getting up frequently. There were also externally noticeable clinical signs that indicated the occurrence of a previous car accident. These included asymmetrical tuber coxae and slight crippling while she was walking. Upon further examination, her rectal temperature (38.7°C), respiration rate (16 breaths/minute), and heart rate were 52 beats/minute. The cervix was fully dilated, and the pelvic cavity was narrowed due to the downward bending of the iliac wing. The fetal forelimbs were lodged in the cervix, and the fetus could not be expelled by traction. Based on the patient’s history and clinical findings, a decision was made to perform a cesarean section under general anesthesia while the patient was in a recumbent position. The exhausted jenny was stabilized with lactated ringer inger’s solution at a drip rate of 10 ml/kg/hr, and fortified procaine penicillin G at 25,000 IU/kg was administered intramuscularly as a prophylactic. Then, she was premedicated with IV xylazine hydrochloride at 1.1 mg/kg and induced with ketamine hydrochloride at 2.2 mg/kg after 5 minutes of xylazine injection. Just after ketamine injection and loss of body balance, she was assisted in lying down in lateral recumbence, and her legs were tied with rope for additional safety. Maintenance anesthesia was achieved with the constant rate infusion (CRI) technique by using a combination of ketamine (7.2 mg/kg/hr) and xylazine (2.1 mg/kg/hr) added to normal saline solution at a rate of 6 drops/second. The surgical site was then widely shaved, washed, and scrubbed with tincture iodine solution as quickly as possible to reduce the time at the recumbent position and anesthetic exposure. Local infiltration of lidocaine was additionally used on the incision line when light general anesthesia was used (during the delivery of a live fetus). The animal was subsequently shifted to the dorsolateral position with the help of assistants. For each cesarean section (CS), different surgical sites were selected. Accordingly, the left lower flank, ventral midline, and left paramedian approaches were used. After proper disinfection, skin incisions were made on the selected sites. During the 1 st CS, a 25 cm long oblique skin incision was made on the lower left flank. At the 2 nd CS, the incision was made on the midline approximately 10 cm from the cranial base of the udder and extended cranially for approximately 30 cm. During the 3 rd CS, a 25 cm long skin incision was made on the left paramedian 5 cm away from the ventral midline. Except during the lower flank approach, after the incision of the subcutaneous tissue and abdominal muscles was made, a large amount of subperitoneal fat was trimmed off to expose the peritoneum. Finally, the peritoneum was incised, and the gravid uterus was exteriorized ( Figure 1C ), while the remaining abdominal organs were packed with sterile drapes to prevent evisceration and contamination of the abdominal cavity. After the uterus was exteriorized and locked into the incision line, a small incision was made parallel to the uterine vasculature, and the incision was extended sufficiently with scissors for easy removal of the fetus and to avoid irregular tearing during fetal removal. The foal's hind legs were straightened and passed to an assistant surgeon for fetal removal while the surgeon was stabilizing the uterus. During live fetus delivery, the foal was immediately passed to the attendant to clean and keep from harming herself while trying to stand and search for a dam ( Figure 1D ). Following the removal of the live fetus, an easily accessible fetal membrane was gently detached and trimmed. However, at the 1 st and 3 rd parturitions, due to late presentation, the fetal membrane was already detached from the uterus and removed, as was the dead fetus, without additional effort. Before uterine closure, procaine penicillin powder was applied to the uterus to control possible intrasurgical infection. The uterine incision was made with a simple continuous suture (biting all layers of the uterine wall) to ensure adequate hemostasis. Simple continuous suturing was oversewed with a Cushing suture pattern using #0 polyglycolic acid (PGA). The drape packed in the abdominal cavity was subsequently removed, and the first layer of the abdominal wall was closed with a simple interrupted suture pattern in all the approaches. Subcutaneous tissue was closed with a continuous interlocking pattern by # 2 polyglycolic acid (PGA), USP 2, Huaian Angel Medical Instruments Co., Ltd., Jiangsu, China). The skin was closed by horizontal mattress during midline and paramedian approaches, while a ford interlocking pattern was used for the lower flank approach. Finally, the surgical site was cleaned with 2% tincture iodine. Upon successful completion of the procedure, jenny recovered from anesthesia and met her foal. Postoperatively, the foal was assisted in sucking her milk by positioning her mouth on the dam’s teat and milking her milk into her mouth until she became strong. Jenny and her foal were kept in the Donkey Health and Welfare Project patient follow-up room and followed there until full recovery. After treatment with fortified procaine penicillin G at 25,000 IU/kg, IM was continued for 5 days, and diclofenac sodium was administered for 3 days to relieve postoperative pain. The surgical wound was cleaned daily with tincture iodine ( Figure 2A&B ) until healing was confirmed. According to the owner, jenny started mating on the 12 th day of the 1 st CS. Accordingly, she was able to give birth to a female foal after 384 days of mating. Even though the owner was advised to keep her indoors until she was permanently sterilized, he lost her willingness, and her 3 rd CS was conducted after 417 days of her 2 nd surgery. In all surgical approaches, subcutaneous swelling was observed on the most ventral part of the incision line, starting from the 2 nd to 4 th day of operation, and regressed within 9 days of onset. The skin sutures were removed on the 14 th and 21 st days after complete wound healing during the flank and ventral abdominal wall approaches, respectively ( Figure 3A&B ). The jenny was in good health at 35 days after the 3 rd operation. Discussion Dystocia in equines is an emergency because of the powerful uterine and abdominal contractions involved in fetal expulsion, resulting in rapid placental separation. As a result, dystocia significantly increases the risk of fetal hypoxia and reduces the likelihood of foal survival 11 . The present case of dystocia was associated with previous pelvic bone damage due to a car accident. This finding is in line with 6 , who reported that pelvic deformities are among the possible indications for cesarean section. During the 1 st parity, it was confirmed that jenny could not give birth without CS due to a previous car accident on her pelvic bone. Therefore, at the 2 nd and 3 rd parity, the animal was presented without prior manipulation for per-vaginal delivery. Therefore, a timely cesarean section was chosen to save both the life of the mother and foal during the 2 nd case. However, during the 3 rd visit, the foal died as the dam was too late for surgery, as she was in the grazing field without close access. Foal survival is high (38%) when the operation is performed early, and terminal cesarean sections carry a poor prognosis for foal survival, as the foal suffers from fatal anoxia because of dehiscence of the allantochorion within 1 or 2 hours of second-stage labor. Hence, if the foal is alive, the operation should be performed with minimum delay 6 . Similarly, in the present case, the foal was found to be alive during early presentation, the viability of the fetus was checked via vaginal examination, and both of her and her life were saved via timely cesarean section. A combination of xylazine, ketamine, and diazepam can be used for induction, while inhalation anesthesia is used for maintenance purposes. However, in the absence of inhalation anesthesia, it can be further maintained by xylazine, ketamine, diazepam, and guaifenesin 6 . In equine patients, anesthetic induction with a combination of ketamine and diazepam produces a fast and safe means of recumbency in emergency or elective procedures. However, diazepam is believed to accumulate in the fetal compartment and cause respiratory depression in the fetus at birth 13 . On the other hand, local anesthesia for cesarean section is considered a lifesaving procedure in very high-risk patients 10 . The present surgical procedure was performed under general anesthesia with a combination of xylazine and ketamine. However, to reduce the fetal concentration of general anesthesia, the anesthesia was kept at the light stage until live fetus delivery, and line infiltration of lidocaine was used concurrently to reduce pain during the incision. Equine dystocia can be managed via different surgical techniques, including ventral flank laparotomy and the paramedian and ventral midline approaches. Most surgeons choose the ventral midline approach under general anesthesia, with the mare in dorsal recumbence tilted slightly toward the surgeon because this approach allows easy exteriorization of the uterus and considerably reduces the intra-abdominal pressure; additionally, the wound can be easily repaired without excessive tension on the sutures 6,14 . Fortunately, in the present case, all three approaches were used consecutively because of their comparative advantages and disadvantages. The ventral midline approach was chosen because of the above-listed advantages and because of the previous description of a cesarean section on the ventral flank. However, during midline and paramedian approach, control of the animal in dorsolateral recumbence requires additional power. The flank approach also causes more stress to animals than does the flank approach if performed under light general anesthesia. Additionally, surgeons need to trim excessive subperitoneal fat in well-conditioned animals. These two approaches were associated with relatively greater ventral edema than was the lower flank approach. Postoperative swelling during the flank approach occurred at the ventral part of the surgical site without the involvement of the incision line. However, swelling in the other two approaches extended to the incision line and took a relatively longer time to disappear. As indicated 6 , other approaches apart from the midline necessitate muscle division, which results in greater hemorrhage and postoperative edema. Similarly, it was observed that there were various large blood vessels encountered during the dissection of abdominal muscles via the flank approach compared with the remaining approaches. However, swelling may not only be associated with the surgical approach but also with the animal species, as it similarly appeared in all the other approaches. With respect to the current midline approach, the risk of incisional hernia was prevented by using an appropriate closure technique and suture material of an appropriate size and strength. 15 reported that midline incisions can be easily repaired without excessive tension on the sutures, and the risk of incisional hernia is negligible. Similarly, during the current midline closure, there was no excessive tension when the patient was in dorsal or dorsolateral recumbency. However, the suture tension increases when the animal moves into the lateral position and is expected to increase when the animal is in the standing position due to the full intestinal load. Therefore, it is difficult to exclude incisional hernias or evisceration unless appropriate suture materials of appropriate size and strength are used. Dorsal recumbency during anesthesia in the mare is more likely to cause hypotension due to aortocaval compression by the gravid uterus than is lateral recumbency 10 . Even though dorsal recumbency allows sufficient space during uterus exteriorization and can reduce tension during wound closure, the current cesarean sections were generated via dorsolateral recumbence to reduce hypotension and pressure on the vertebral column. If the placenta remains attached to the endometrium, it is better not to attempt manual separation, as this may lead to profuse bleeding, and oxytocin is suggested for the completion of uterine closure or if the placenta is not expelled within 4 hours to assist in uterine contraction and placental expulsion 6 . In the current live fetus delivery method, an easily accessible part of the fetal membrane was removed to promote easier uterine closure by avoiding the incorporation of the placenta in the suture line. The remaining part was easily removed per vagina after 9 hours of operation following complete detachment by uterine contraction without oxytocin injection. Therefore, if the patient presented with a fully dilated cervix, vaginal removal of the remaining placenta some hours after the procedure was found to be effective at minimizing operation time. The equine uterus needs fast closure to achieve complete hemostasis of diffuse bleeding. Conclusions This case is the first ever compiled case report on donkeys both in type and technique. Thus, we were able to describe different approaches for cesarean section in equines. Moreover, due to the anatomic nature of the equine uterus, bleeding from hysterotomy incisions is more common than in other animal species. Therefore, in all approaches, the first layer of the uterine incision should be closed with simple continuous suture (biting all uterine layers) to prevent diffuse bleeding from the hysterectomy incision line. It was also concluded that subcutaneous edema is unavoidable in donkeys compared to other animal species. Declarations Competing interests: - No competing interest Consent for Publication: - Attached under annexes Author contributions C.T.F. and Y.D.D. conducted surgical procedures and wrote the main manuscript. J.D.K: participated in the final edition of the manuscript. All the authors read and approved the final manuscript for submission for publication. Funds : No funding was received for the preparation of this manuscript. References Thangamani, A., Srinivas, M., Prasad, B. & Kumar, L. Periparturient event and dystocia in equine- A Review. Int. J. Sci. Environ. 7 , 648–658 (2018). Evans, L. & Crane, M. The clinical companion of the donkey. 267 (2018). Chauhan, P. M., Sindhi, S. H. & Thakor, K. B. Fetal dystocia due to dorso-pubic position and postural defects in a jenny: A case report. Vet. World 6 , 116–117 (2013). Kristina.G et al. Dystocia—A True Equine Emergency. Clin Tech Equine Pr. 5 , 145–153 (2006). Samper, J. C., Act, D. & Plow, T. A. How to deal with dystocia and retained placenta in the field. In AAEP Proceedings vol. 58 359--361 (2012). Purohit, G. N. Dystocia and its management in the mare. J. Livest. Sci. 2 , (2019). Sheetal, S. K. Et al. Management of dystocia due to primary uterine inertia. 7 , 584–587 (2018). Purohit, G. N. Intrapartum conditions and their management in mare. Purohit J. Livest. Sci. 2 , 20–37 (2019). Chauhan, P., Sindhi, S. & Thakor, K. Fetal dystocia due to dorso-pubic position and postural defects in a Jenny: A case report. Vet World 6 , 116–118 (2013). Ninu, A. R. Et al. Cesarean in mare by Marcenac incision under local anesthesia. Iran. J. Vet. Res. 16 , 117–119 (2015). Maaskant, A., Bruijn, C. M. De, Schutrups, A. H. & Stout, T. A. E. Dystocia in Friesian mares: Prevalence, causes and outcome following cesarean section. Equine Vet. Educ. 190–195 (2021). Rioja, E., Cernicchiaro, N., Costa, M. & Valverde, A. Perioperative risk factors for mortality and length of hospitalization in mares with dystocia undergoing general anesthesia: A retrospective study. Canadain Vet. J. 53 , 502–510 (2012). Bidwell, L., Embertson, R., Bone, N. & Ru, M. Diazepam levels in foals after dystocia birth. Proc. 54th Annu. Conv. Am. Assoc. Equine Pract. San Diego, California, December 6-10 2008. 54 , 286–287 (2008). Sharma, A. Et al. Dystocia due to breech presentation and cesarean under local anesthesia and sedation in a mare. SVU-International J. Vet. Sci. 4 , 16–21 (2021). Dutt, R. Et al. Surgical management of dystocia due to fetal deformity in a mare. (2020). Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5035757","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":349833887,"identity":"da241cc5-aecf-4e58-ae81-a6ff832b287c","order_by":0,"name":"Cheru Telila 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06:41:37","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-5035757/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5035757/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64186599,"identity":"c11af2af-5d4f-4f92-ace2-d0d754977992","added_by":"auto","created_at":"2024-09-09 16:27:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":457599,"visible":true,"origin":"","legend":"\u003cp\u003eCase presentation and surgical delivery of the fetus. \u003cstrong\u003eA\u003c/strong\u003e and \u003cstrong\u003eB)\u003c/strong\u003e Jenny presentation during 1st and 2\u003csup\u003end\u003c/sup\u003e parity respectively. \u003cstrong\u003eC)\u003c/strong\u003e Midline incision and fetal hind limb locked in the incision site. \u003cstrong\u003eD)\u003c/strong\u003e Live fetus trying to stand just after delivery\u003c/p\u003e","description":"","filename":"Picture1.png","url":"https://assets-eu.researchsquare.com/files/rs-5035757/v1/76489524e1a87951c5aa4a6e.png"},{"id":64167951,"identity":"8ade03d9-1648-403f-a183-42a8efa636c0","added_by":"auto","created_at":"2024-09-09 09:55:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":266263,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative wound management and patient care in the Donkey Sanctuary and Animal Welfare Project during 2\u003csup\u003end\u003c/sup\u003e and 3\u003csup\u003erd\u003c/sup\u003e parity. \u003cstrong\u003eA)\u003c/strong\u003e Ventral midline approach CS. \u003cstrong\u003eB\u003c/strong\u003e) left paramedian approach CS.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-5035757/v1/30d2aba1a068e0b28b458abb.png"},{"id":64167952,"identity":"43388b83-ece8-4557-a3e2-89820b95a8d0","added_by":"auto","created_at":"2024-09-09 09:55:15","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":259777,"visible":true,"origin":"","legend":"\u003cp\u003eRecovery status of the jenny. \u003cstrong\u003eA) \u003c/strong\u003eOn the 14\u003csup\u003eth\u003c/sup\u003e day of left flank CS when she was presented for suture removal and after started mating. \u003cstrong\u003eB)\u003c/strong\u003e On the 8\u003csup\u003eth\u003c/sup\u003e day of ventral midline CS with her cute foal\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-5035757/v1/24adc77d46ddf22605479c2a.png"},{"id":64188078,"identity":"f62ce1e9-bfb7-4d51-85d3-86381428592e","added_by":"auto","created_at":"2024-09-09 16:52:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1458138,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5035757/v1/389ddcce-7683-49f5-8612-b97af0c00bb4.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eMultiple Cesarean Section Jenny\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eEquine species are long-day seasonal breeders, and their parturition process is very similar to that of other domestic animals in many ways\u0026nbsp;\u003csup\u003e1\u003c/sup\u003e.\u0026nbsp;The\u0026nbsp;length of\u0026nbsp;the\u0026nbsp;pregnancy period is 365 to 376 days,\u0026nbsp;but extreme variations range from 340 to 395 days,\u0026nbsp;and parturition is a rapid and violent feature\u0026nbsp;\u003csup\u003e2,3\u003c/sup\u003e. Foaling is the process of giving birth to\u0026nbsp;a\u0026nbsp;foal\u0026nbsp;and\u0026nbsp;is\u0026nbsp;a\u0026nbsp;prompt and forceful event in equine breeding\u0026nbsp;\u003csup\u003e4\u003c/sup\u003e. During normal foaling,\u0026nbsp;the mare\u0026nbsp;becomes\u0026nbsp;restless,\u0026nbsp;sweats, urinates frequently, contractions begin,\u0026nbsp;and the\u0026nbsp;fetus\u0026nbsp;changes position so that\u0026nbsp;her\u0026nbsp;head and forelimbs are in the birth canal as stage I\u0026nbsp;progresses,\u0026nbsp;which can last between 1\u0026nbsp;and\u0026nbsp;4 hours\u0026nbsp;\u003csup\u003e4,5\u003c/sup\u003e. Stage II is the time of\u0026nbsp;fetal\u0026nbsp;delivery,\u0026nbsp;which usually lasts less than 40 minutes. It is characterized by the appearance of\u0026nbsp;a\u0026nbsp;water bag or the commencement of forcible straining, active abdominal contractions,\u0026nbsp;and the\u0026nbsp;appearance of the\u0026nbsp;fetal\u0026nbsp;leg, and\u0026nbsp;mothers\u0026nbsp;may choose to stand or lie down for birth\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e. Delivery of the\u0026nbsp;fetal\u0026nbsp;membranes\u0026nbsp;was\u0026nbsp;considered stage III,\u0026nbsp;and\u0026nbsp;the patient was\u0026nbsp;considered\u0026nbsp;to be in\u0026nbsp;normal\u0026nbsp;condition\u0026nbsp;if it\u0026nbsp;expelled\u0026nbsp;within the first 3 hours after parturition\u0026nbsp;\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Dystocia is defined as\u0026nbsp;a\u0026nbsp;difficult birth that reduces neonatal viability, causes maternal injury/death, or requires assistance during delivery\u0026nbsp;\u003csup\u003e7,8\u003c/sup\u003e.\u0026nbsp;However, this procedure is\u0026nbsp;challenging for many equine practitioners\u0026nbsp;\u003csup\u003e4\u003c/sup\u003e.\u0026nbsp;Dystocia in jenny is very rare and estimated to\u0026nbsp;account for 1-4% of foales,\u0026nbsp;and it can be caused by maternal problems\u0026nbsp;such as\u0026nbsp;abnormal pelvic conformation as a result of a previous injury, exhaustion or uterine inertia;\u0026nbsp;infection such as\u0026nbsp;equine herpesvirus,\u0026nbsp;which causes abortion in late pregnancy;\u0026nbsp;or\u0026nbsp;the\u0026nbsp;absence of expulsive forces.\u0026nbsp;The major\u0026nbsp;fetal\u0026nbsp;problems related to dystocia\u0026nbsp;include fetal\u0026nbsp;malposition, size, malformation, and twins\u0026nbsp;\u003csup\u003e4,9\u003c/sup\u003e. Among these\u0026nbsp;abnormalities, malposturing of long fetal\u0026nbsp;extremities is considered the most common cause of dystocia in equines,\u0026nbsp;although\u0026nbsp;positional and presentational abnormalities occur to a lesser extent\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Dystocia\u0026nbsp;was\u0026nbsp;declared when the 2\u003csup\u003end\u003c/sup\u003e stage of parturition\u0026nbsp;exceeded\u0026nbsp;20 minutes without\u0026nbsp;fetal\u0026nbsp;expulsion\u0026nbsp;during the\u0026nbsp;mare. Thus, fetal\u0026nbsp;mortality and future mare fertility\u0026nbsp;depend\u0026nbsp;on\u0026nbsp;the\u0026nbsp;time and decisions made during foaling\u0026nbsp;\u003csup\u003e4\u003c/sup\u003e. A delay in labor may result in deterioration of fetal health when oxygen delivery\u0026nbsp;decreases\u0026nbsp;as the placenta begins to separate from the uterus. Equine dystocia is regarded as a true emergency\u0026nbsp;because\u0026nbsp;it\u0026nbsp;threatens\u0026nbsp;the dam and\u0026nbsp;fetus\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e.\u0026nbsp;The risks are increased in small donkeys because of the domed large forehead of some foals\u0026nbsp;\u003csup\u003e3\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe choice of management may depend on the status of the\u0026nbsp;fetus, duration and severity of the dystocia, economic value of the dam and\u0026nbsp;fetus, clinician expertise, client preference, and facilities available. Prompt assessment of the cause of dystocia is important for rapid decision-making\u0026nbsp;concerning\u0026nbsp;the course of action\u0026nbsp;\u003csup\u003e5\u003c/sup\u003e. If a\u0026nbsp;fetus\u0026nbsp;is alive, vaginal delivery may be attempted.\u0026nbsp;However,\u0026nbsp;if a live foal\u0026nbsp;in an\u0026nbsp;abnormal position\u0026nbsp;cannot\u0026nbsp;be repositioned per vagina, a cesarean section should be\u0026nbsp;chosen\u0026nbsp;as soon as possible\u0026nbsp;\u003csup\u003e11\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAn equine\u0026nbsp;cesarean section is an emergency\u0026nbsp;in which a\u0026nbsp;veterinarian should decide on the need for general anesthesia,\u0026nbsp;and the choice is made after considering the safety and comfort of the patient and fetus\u0026nbsp;and the\u0026nbsp;comfort of the surgeon so that the surgery\u0026nbsp;can be\u0026nbsp;completed rapidly\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e. Equine patients have a greater risk of mortality and morbidity related to general anesthesia than other domestic species and humans\u0026nbsp;\u003csup\u003e12\u003c/sup\u003e. Therefore, for cesarean section,\u0026nbsp;local anesthesia is considered a lifesaving procedure in very high-risk patients\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eThe management of dystocia in equines is relatively difficult compared to that in other large animals. Additionally, due to the absence of well-described published papers on cesarean section in donkeys, this procedure has been threatening both the life of the dam and the fetus after unsuccessful manual or surgical intervention. Therefore, the present case report aims to describe different cesarean section approaches and their outcomes in jenny.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 4-year-old local breed jenny weighing\u0026nbsp;approximately 140 kg was used\u0026nbsp;for surgical intervention\u0026nbsp;for\u0026nbsp;dystocia for three consecutive years. Jenny faced a car accident,\u0026nbsp;and her pelvic bone was damaged when she was 2 years of age. At the 1\u003csup\u003est\u003c/sup\u003e parity, signs of labor were noticed during the first 4 hours of labor. However, she became exhausted and lay down\u0026nbsp;(\u003cstrong\u003eFigure\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1A\u003c/strong\u003e) after being manipulated by two different para veterinarians at different\u0026nbsp;times\u0026nbsp;before reporting to\u0026nbsp;a\u0026nbsp;veterinary teaching hospital (VTH). During the 2\u003csup\u003end\u0026nbsp;\u003c/sup\u003e(\u003cstrong\u003eFigure\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1B\u003c/strong\u003e) and 3\u003csup\u003erd\u003c/sup\u003e parity, she was directly presented to the hospital without any prior intervention. At that time,\u0026nbsp;she was straining, lying down and getting up frequently. There were also externally noticeable clinical signs that indicated the\u0026nbsp;occurrence\u0026nbsp;of a previous car accident. These\u0026nbsp;included\u0026nbsp;asymmetrical tuber coxae and slight crippling while she was walking.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Upon\u0026nbsp;further\u0026nbsp;examination, her\u0026nbsp;rectal temperature (38.7\u0026deg;C), respiration\u0026nbsp;rate (16 breaths/minute), and heart rate\u0026nbsp;were\u0026nbsp;52 beats/minute. The cervix was fully dilated,\u0026nbsp;and\u0026nbsp;the\u0026nbsp;pelvic cavity was narrowed due to the downward bending of the iliac wing. The\u0026nbsp;fetal\u0026nbsp;forelimbs were lodged in the cervix,\u0026nbsp;and\u0026nbsp;the fetus could not\u0026nbsp;be expelled by traction. Based on\u0026nbsp;the patient\u0026rsquo;s\u0026nbsp;history and clinical findings,\u0026nbsp;a\u0026nbsp;decision was made to perform a cesarean section under general anesthesia\u0026nbsp;while the patient was in a\u0026nbsp;recumbent\u0026nbsp;position.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;The exhausted\u0026nbsp;jenny was stabilized with lactated ringer\u0026nbsp; \u0026nbsp;\u0026nbsp;inger\u0026rsquo;s\u0026nbsp;solution at a drip rate of\u0026nbsp;10 ml/kg/hr,\u0026nbsp;and fortified procaine penicillin G at 25,000 IU/kg was administered intramuscularly as\u0026nbsp;a\u0026nbsp;prophylactic. Then,\u0026nbsp;she was premedicated with IV xylazine hydrochloride at 1.1 mg/kg and induced with ketamine hydrochloride at 2.2 mg/kg after 5 minutes of xylazine injection. Just after ketamine injection and loss of body balance,\u0026nbsp;she was assisted\u0026nbsp;in lying\u0026nbsp;down in lateral recumbence,\u0026nbsp;and her legs were tied with rope for additional safety.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Maintenance\u0026nbsp;anesthesia was achieved with\u0026nbsp;the\u0026nbsp;constant rate infusion (CRI) technique by using a combination of ketamine\u0026nbsp;(7.2 mg/kg/hr)\u0026nbsp;and xylazine\u0026nbsp;(2.1 mg/kg/hr)\u0026nbsp;added\u0026nbsp;to\u0026nbsp;normal saline solution at\u0026nbsp;a\u0026nbsp;rate of 6 drops/second.\u0026nbsp;The\u0026nbsp;surgical site was\u0026nbsp;then\u0026nbsp;widely shaved, washed, and scrubbed with tincture iodine solution as\u0026nbsp;quickly\u0026nbsp;as possible to reduce\u0026nbsp;the\u0026nbsp;time at\u0026nbsp;the\u0026nbsp;recumbent position and anesthetic exposure. Local infiltration of lidocaine was additionally used on the incision line when light general anesthesia was used (during the delivery of a live fetus).\u0026nbsp;The\u0026nbsp;animal was\u0026nbsp;subsequently\u0026nbsp;shifted to the\u0026nbsp;dorsolateral\u0026nbsp;position with the help of assistants.\u003c/p\u003e\n\u003cp\u003eFor each cesarean section (CS),\u0026nbsp;different surgical sites were\u0026nbsp;selected.\u0026nbsp;Accordingly, the left lower flank, ventral midline, and left paramedian approaches were used. After proper\u0026nbsp;disinfection, skin incisions were made on the selected sites.\u0026nbsp;During the 1\u003csup\u003est\u003c/sup\u003e CS,\u0026nbsp;a\u0026nbsp;25 cm long oblique skin incision was made on the lower\u0026nbsp;left flank.\u0026nbsp;At the 2\u003csup\u003end\u003c/sup\u003e CS, the incision was\u0026nbsp;made\u0026nbsp;on the midline approximately 10 cm from the cranial base of the udder and extended cranially for\u0026nbsp;approximately 30 cm. During the 3\u003csup\u003erd\u003c/sup\u003e CS, a\u0026nbsp;25 cm\u0026nbsp;long skin incision was made on the left paramedian 5 cm away from the ventral midline. Except during the lower flank approach,\u0026nbsp;after the incision of\u0026nbsp;the\u0026nbsp;subcutaneous tissue and abdominal muscles\u0026nbsp;was made, a large amount of\u0026nbsp;subperitoneal fat was trimmed off to expose the peritoneum. Finally, the peritoneum was incised,\u0026nbsp;and the gravid uterus was exteriorized (\u003cstrong\u003eFigure\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1C\u003c/strong\u003e),\u0026nbsp;while the remaining abdominal organs were packed with sterile drapes to prevent evisceration and contamination of the abdominal cavity. After\u0026nbsp;the uterus was exteriorized and locked into the\u0026nbsp;incision line, a small incision was made parallel to\u0026nbsp;the\u0026nbsp;uterine\u0026nbsp;vasculature, and the incision was extended sufficiently with scissors for easy removal of the\u0026nbsp;fetus\u0026nbsp;and to avoid irregular tearing during\u0026nbsp;fetal\u0026nbsp;removal.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;The\u0026nbsp;foal\u0026apos;s hind legs were straightened and passed to\u0026nbsp;an\u0026nbsp;assistant surgeon for\u0026nbsp;fetal\u0026nbsp;removal while the surgeon was stabilizing the uterus. During live\u0026nbsp;fetus\u0026nbsp;delivery, the foal was immediately passed to\u0026nbsp;the attendant\u0026nbsp;to clean and keep\u0026nbsp;from harming herself while trying to stand and search for\u0026nbsp;a\u0026nbsp;dam (\u003cstrong\u003eFigure\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1D\u003c/strong\u003e). Following the removal of the live\u0026nbsp;fetus, an easily accessible\u0026nbsp;fetal\u0026nbsp;membrane was gently detached and trimmed.\u0026nbsp;However,\u0026nbsp;at the\u0026nbsp;1\u003csup\u003est\u003c/sup\u003e and 3\u003csup\u003erd\u003c/sup\u003e parturitions,\u0026nbsp;due to late presentation,\u0026nbsp;the\u0026nbsp;fetal\u0026nbsp;membrane was already detached from the uterus and removed, as was the\u0026nbsp;dead\u0026nbsp;fetus,\u0026nbsp;without additional effort.\u003c/p\u003e\n\u003cp\u003eBefore uterine closure, procaine penicillin powder was applied to the uterus to control possible intrasurgical infection. The uterine incision was\u0026nbsp;made\u0026nbsp;with\u0026nbsp;a\u0026nbsp;simple continuous suture (biting all layers of the uterine wall) to ensure adequate hemostasis. Simple continuous\u0026nbsp;suturing\u0026nbsp;was oversewed with\u0026nbsp;a Cushing\u0026nbsp;suture pattern using\u0026nbsp;#0\u0026nbsp;polyglycolic acid (PGA).\u0026nbsp;The\u0026nbsp;drape packed in the abdominal cavity was\u0026nbsp;subsequently\u0026nbsp;removed,\u0026nbsp;and the first layer of the abdominal wall was closed with a simple interrupted suture pattern in all\u0026nbsp;the\u0026nbsp;approaches. Subcutaneous tissue was closed with\u0026nbsp;a\u0026nbsp;continuous interlocking pattern by # 2 polyglycolic acid (PGA), USP 2, Huaian Angel Medical Instruments Co.,\u0026nbsp;Ltd., Jiangsu, China). The skin was closed by horizontal mattress during midline and paramedian approaches,\u0026nbsp;while\u0026nbsp;a\u0026nbsp;ford interlocking pattern was used\u0026nbsp;for\u0026nbsp;the lower flank approach. Finally, the surgical site was cleaned with 2% tincture iodine.\u0026nbsp;Upon\u0026nbsp;successful completion of the procedure, jenny recovered from anesthesia and met her foal.\u003c/p\u003e\n\u003cp\u003ePostoperatively,\u0026nbsp;the foal was assisted\u0026nbsp;in sucking her\u0026nbsp;milk by positioning her mouth on\u0026nbsp;the\u0026nbsp;dam\u0026rsquo;s teat and milking\u0026nbsp;her milk\u0026nbsp;into her mouth\u0026nbsp;until\u0026nbsp;she became strong. Jenny and her foal were kept in\u0026nbsp;the\u0026nbsp;Donkey Health and Welfare Project patient follow-up room and followed there until full recovery.\u0026nbsp;After treatment with fortified\u0026nbsp;procaine penicillin G\u0026nbsp;at\u0026nbsp;25,000 IU/kg, IM was continued for 5 days,\u0026nbsp;and diclofenac sodium was administered for 3 days to relieve\u0026nbsp;postoperative\u0026nbsp;pain.\u0026nbsp;The surgical\u0026nbsp;wound was cleaned daily with tincture iodine (\u003cstrong\u003eFigure 2A\u0026amp;B\u003c/strong\u003e) until healing was confirmed. According to the owner, jenny started mating on the 12\u003csup\u003eth\u003c/sup\u003e day of\u0026nbsp;the\u0026nbsp;1\u003csup\u003est\u003c/sup\u003e CS. Accordingly, she was able to give birth to a female foal after 384 days of mating. Even though the owner was\u0026nbsp;advised\u0026nbsp;to keep her indoors\u0026nbsp;until\u0026nbsp;she was permanently sterilized,\u0026nbsp;he lost\u0026nbsp;her\u0026nbsp;willingness,\u0026nbsp;and\u0026nbsp;her\u0026nbsp;3\u003csup\u003erd\u003c/sup\u003e CS was conducted after 417 days of\u0026nbsp;her\u0026nbsp;2\u003csup\u003end\u003c/sup\u003e surgery.\u003c/p\u003e\n\u003cp\u003eIn all surgical approaches, subcutaneous swelling was observed on the most ventral part of the incision line,\u0026nbsp;starting from the 2\u003csup\u003end\u003c/sup\u003e to 4\u003csup\u003eth\u003c/sup\u003e day of operation,\u0026nbsp;and regressed within 9 days of onset. The skin sutures were removed on the 14\u003csup\u003eth\u003c/sup\u003e and 21\u003csup\u003est\u003c/sup\u003e days\u0026nbsp;after complete wound healing during the flank and ventral abdominal wall approaches,\u0026nbsp;respectively \u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003eFigure 3A\u0026amp;B\u003c/strong\u003e). The jenny was in good health\u0026nbsp;at\u0026nbsp;35 days\u0026nbsp;after\u0026nbsp;the 3\u003csup\u003erd\u003c/sup\u003e operation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDystocia in equines is an emergency because of the powerful uterine and abdominal contractions involved in\u0026nbsp;fetal\u0026nbsp;expulsion,\u0026nbsp;resulting in rapid placental separation. As a result,\u0026nbsp;dystocia significantly increases the risk of\u0026nbsp;fetal\u0026nbsp;hypoxia and reduces the likelihood of foal survival\u0026nbsp;\u003csup\u003e11\u003c/sup\u003e. The present\u0026nbsp;case of\u0026nbsp;dystocia was associated with previous pelvic bone damage due to a car accident. This\u0026nbsp;finding\u0026nbsp;is in line with\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e, who\u0026nbsp;reported\u0026nbsp;that\u0026nbsp;pelvic deformities are among\u0026nbsp;the\u0026nbsp;possible indications for cesarean section. During\u0026nbsp;the\u0026nbsp;1\u003csup\u003est\u003c/sup\u003e parity, it was confirmed that jenny\u0026nbsp;could not\u0026nbsp;give birth without CS due to a previous car accident on her pelvic bone. Therefore, at the 2\u003csup\u003end\u003c/sup\u003e and 3\u003csup\u003erd\u003c/sup\u003e parity, the animal was presented without prior manipulation for per-vaginal delivery. Therefore, a timely cesarean section was\u0026nbsp;chosen\u0026nbsp;to save both the life of the mother and foal during the 2\u003csup\u003end\u003c/sup\u003e case.\u0026nbsp;However,\u0026nbsp;during the 3\u003csup\u003erd\u003c/sup\u003e visit, the foal died as the dam was too late for surgery,\u0026nbsp;as she was in the grazing field without close\u0026nbsp;access.\u003c/p\u003e\n\u003cp\u003eFoal survival is high (38%) when the operation is performed early,\u0026nbsp;and terminal cesarean sections carry a poor prognosis for foal survival,\u0026nbsp;as the foal suffers from fatal anoxia because of dehiscence of the allantochorion within 1 or 2 hours of second-stage labor. Hence, if the foal is alive,\u0026nbsp;the operation should be performed with minimum delay\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e. Similarly, in the present case,\u0026nbsp;the foal was found\u0026nbsp;to be\u0026nbsp;alive during early presentation,\u0026nbsp;the viability of the\u0026nbsp;fetus\u0026nbsp;was checked\u0026nbsp;via\u0026nbsp;vaginal examination,\u0026nbsp;and both\u0026nbsp;of her and her life\u0026nbsp;were saved\u0026nbsp;via\u0026nbsp;timely\u0026nbsp;cesarean\u0026nbsp;section.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;A combination of xylazine, ketamine, and diazepam can be used for induction, while inhalation anesthesia is used for maintenance purposes.\u0026nbsp;However,\u0026nbsp;in the absence of inhalation anesthesia, it can be\u0026nbsp;further\u0026nbsp;maintained by xylazine, ketamine, diazepam, and guaifenesin\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e. In equine patients, anesthetic induction with a combination of ketamine and diazepam produces a fast and safe means of recumbency in emergency or elective procedures. However,\u0026nbsp;diazepam\u0026nbsp;is believed\u0026nbsp;to accumulate\u0026nbsp;in the\u0026nbsp;fetal\u0026nbsp;compartment and\u0026nbsp;cause\u0026nbsp;respiratory depression in the\u0026nbsp;fetus\u0026nbsp;at birth\u0026nbsp;\u003csup\u003e13\u003c/sup\u003e. On the other hand, local anesthesia for cesarean section is considered a lifesaving procedure in very high-risk patients\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e. The present surgical\u0026nbsp;procedure\u0026nbsp;was performed under general anesthesia with a combination of xylazine and ketamine. However, to reduce the\u0026nbsp;fetal\u0026nbsp;concentration of general\u0026nbsp;anesthesia, the anesthesia\u0026nbsp;was kept at\u0026nbsp;the\u0026nbsp;light stage\u0026nbsp;until\u0026nbsp;live\u0026nbsp;fetus\u0026nbsp;delivery, and line infiltration of lidocaine was used concurrently to reduce pain during\u0026nbsp;the\u0026nbsp;incision.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;Equine dystocia can be managed\u0026nbsp;via\u0026nbsp;different surgical techniques,\u0026nbsp;including ventral flank laparotomy\u0026nbsp;and the\u0026nbsp;paramedian and ventral midline\u0026nbsp;approaches. Most surgeons choose the ventral midline approach under general anesthesia, with the mare in dorsal recumbence tilted slightly\u0026nbsp;toward\u0026nbsp;the surgeon because\u0026nbsp;this approach\u0026nbsp;allows easy exteriorization of the uterus\u0026nbsp;and\u0026nbsp;considerably reduces the intra-abdominal pressure; additionally,\u0026nbsp;the wound can be easily repaired without excessive tension on the sutures\u0026nbsp;\u003csup\u003e6,14\u003c/sup\u003e. Fortunately, in the\u0026nbsp;present\u0026nbsp;case, all three approaches were used consecutively\u0026nbsp;because of\u0026nbsp;their comparative advantages and disadvantages. The ventral midline\u0026nbsp;approach was\u0026nbsp;chosen because of the above-listed advantages and\u0026nbsp;because of the\u0026nbsp;previous\u0026nbsp;description of a\u0026nbsp;cesarean section on the ventral flank. However, during midline and paramedian approach,\u0026nbsp;control of the animal in dorsolateral recumbence\u0026nbsp;requires\u0026nbsp;additional power.\u0026nbsp;The flank approach\u0026nbsp;also causes more stress to\u0026nbsp;animals\u0026nbsp;than\u0026nbsp;does\u0026nbsp;the flank approach if\u0026nbsp;performed\u0026nbsp;under light general anesthesia.\u0026nbsp;Additionally,\u0026nbsp;surgeons need\u0026nbsp;to trim excessive subperitoneal fat in well-conditioned\u0026nbsp;animals. These two approaches were associated with relatively\u0026nbsp;greater\u0026nbsp;ventral edema\u0026nbsp;than was\u0026nbsp;the lower flank approach. Postoperative swelling during the flank approach\u0026nbsp;occurred\u0026nbsp;at the ventral part of the surgical site without the involvement of the incision line. However, swelling in\u0026nbsp;the other\u0026nbsp;two approaches extended to the incision line and took a\u0026nbsp;relatively\u0026nbsp;longer time to disappear. As indicated\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e other approaches apart from\u0026nbsp;the\u0026nbsp;midline necessitate muscle division, which results in greater hemorrhage and postoperative edema. Similarly, it was observed that there were various large blood vessels encountered during the dissection of abdominal muscles\u0026nbsp;via\u0026nbsp;the flank approach\u0026nbsp;compared with\u0026nbsp;the remaining approaches.\u0026nbsp;However,\u0026nbsp;swelling may not only be associated with the surgical approach but also with\u0026nbsp;the\u0026nbsp;animal species,\u0026nbsp;as it similarly appeared in all\u0026nbsp;the other\u0026nbsp;approaches.\u003c/p\u003e\n\u003cp\u003eWith respect to\u0026nbsp;the current midline approach, the risk of incisional hernia was prevented by using an appropriate closure technique and suture material\u0026nbsp;of\u0026nbsp;an appropriate size and strength.\u0026nbsp;\u003csup\u003e15\u003c/sup\u003e reported that\u0026nbsp;midline\u0026nbsp;incisions\u0026nbsp;can be easily repaired without excessive tension on the sutures,\u0026nbsp;and the risk of incisional hernia is negligible. Similarly,\u0026nbsp;during\u0026nbsp;the current midline closure, there was no excessive tension when the patient\u0026nbsp;was\u0026nbsp;in dorsal\u0026nbsp;or\u0026nbsp;dorsolateral recumbency.\u0026nbsp;However, the suture tension increases when the animal moves into\u0026nbsp;the\u0026nbsp;lateral position and is expected to\u0026nbsp;increase when the animal is\u0026nbsp;in the standing position due to\u0026nbsp;the\u0026nbsp;full intestinal load. Therefore, it is difficult to\u0026nbsp;exclude\u0026nbsp;incisional\u0026nbsp;hernias\u0026nbsp;or evisceration unless appropriate suture\u0026nbsp;materials of\u0026nbsp;appropriate size and strength\u0026nbsp;are\u0026nbsp;used. Dorsal recumbency during anesthesia in the mare is more likely to cause hypotension due to aortocaval compression by the gravid uterus than\u0026nbsp;is\u0026nbsp;lateral recumbency\u0026nbsp;\u003csup\u003e10\u003c/sup\u003e. Even though dorsal recumbency allows sufficient space during uterus exteriorization and can reduce tension during wound closure, the current cesarean sections were\u0026nbsp;generated via\u0026nbsp;dorsolateral recumbence to reduce hypotension and pressure on the vertebral column.\u003c/p\u003e\n\u003cp\u003eIf the placenta remains attached to the endometrium, it is better not to attempt manual separation,\u0026nbsp;as this may lead to profuse bleeding,\u0026nbsp;and oxytocin is suggested\u0026nbsp;for the\u0026nbsp;completion of uterine closure or if the placenta is not expelled within 4 hours to assist in uterine contraction and placental expulsion\u0026nbsp;\u003csup\u003e6\u003c/sup\u003e. In the current live\u0026nbsp;fetus\u0026nbsp;delivery\u0026nbsp;method, an easily accessible part of the\u0026nbsp;fetal\u0026nbsp;membrane was removed to promote easier uterine closure by avoiding the incorporation of the placenta in the suture line. The remaining part was easily removed per vagina after 9 hours of operation following complete detachment by uterine contraction without oxytocin injection. Therefore, if the\u0026nbsp;patient\u0026nbsp;presented with\u0026nbsp;a\u0026nbsp;fully dilated cervix, vaginal removal of the remaining placenta some hours\u0026nbsp;after\u0026nbsp;the procedure was found to\u0026nbsp;be effective at minimizing\u0026nbsp;operation time.\u0026nbsp;The\u0026nbsp;equine uterus needs fast closure to\u0026nbsp;achieve\u0026nbsp;complete hemostasis of\u0026nbsp;diffuse\u0026nbsp;bleeding.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis case is the first ever compiled case report on donkeys both in type and technique. Thus, we were able to describe different approaches for cesarean section in equines. Moreover, due to the anatomic nature of the equine uterus, bleeding from hysterotomy incisions is more common than in other animal species. Therefore, in all approaches, the first layer of the uterine incision should be closed with simple continuous suture (biting all uterine layers) to prevent diffuse bleeding from the hysterectomy incision line. It was also concluded that subcutaneous edema is unavoidable in donkeys compared to other animal species.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting interests: -\u0026nbsp;\u003c/strong\u003eNo competing interest\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication: -\u0026nbsp;\u003c/strong\u003eAttached under annexes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.T.F.\u0026nbsp;and Y.D.D.\u0026nbsp;conducted surgical procedures and wrote the main manuscript. J.D.K: participated in the final edition of the manuscript.\u0026nbsp;All\u0026nbsp;the\u0026nbsp;authors read and approved the final manuscript\u0026nbsp;for\u0026nbsp;submission for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunds\u003c/strong\u003e: No funding was received for the preparation of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThangamani, A., Srinivas, M., Prasad, B. \u0026amp; Kumar, L. Periparturient event and dystocia in equine- A Review. \u003cem\u003eInt. J. Sci. Environ.\u003c/em\u003e \u003cstrong\u003e7\u003c/strong\u003e, 648\u0026ndash;658 (2018).\u003c/li\u003e\n\u003cli\u003eEvans, L. \u0026amp; Crane, M. The clinical companion of the donkey. 267 (2018).\u003c/li\u003e\n\u003cli\u003eChauhan, P. M., Sindhi, S. H. \u0026amp; Thakor, K. B. Fetal dystocia due to dorso-pubic position and postural defects in a jenny: A case report. \u003cem\u003eVet. World\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 116\u0026ndash;117 (2013).\u003c/li\u003e\n\u003cli\u003eKristina.G \u003cem\u003eet al.\u003c/em\u003e Dystocia\u0026mdash;A True Equine Emergency. \u003cem\u003eClin Tech Equine Pr.\u003c/em\u003e \u003cstrong\u003e5\u003c/strong\u003e, 145\u0026ndash;153 (2006).\u003c/li\u003e\n\u003cli\u003eSamper, J. C., Act, D. \u0026amp; Plow, T. A. How to deal with dystocia and retained placenta in the field. In \u003cem\u003eAAEP Proceedings\u003c/em\u003e vol. 58 359--361 (2012).\u003c/li\u003e\n\u003cli\u003ePurohit, G. N. Dystocia and its management in the mare. \u003cem\u003eJ. Livest. Sci.\u003c/em\u003e \u003cstrong\u003e2\u003c/strong\u003e, (2019).\u003c/li\u003e\n\u003cli\u003eSheetal, S. K. \u003cem\u003eEt al.\u003c/em\u003e Management of dystocia due to primary uterine inertia. \u003cstrong\u003e7\u003c/strong\u003e, 584\u0026ndash;587 (2018).\u003c/li\u003e\n\u003cli\u003ePurohit, G. N. Intrapartum conditions and their management in mare. \u003cem\u003ePurohit J. Livest. Sci.\u003c/em\u003e \u003cstrong\u003e2\u003c/strong\u003e, 20\u0026ndash;37 (2019).\u003c/li\u003e\n\u003cli\u003eChauhan, P., Sindhi, S. \u0026amp; Thakor, K. Fetal dystocia due to dorso-pubic position and postural defects in a Jenny: A case report. \u003cem\u003eVet World\u003c/em\u003e \u003cstrong\u003e6\u003c/strong\u003e, 116\u0026ndash;118 (2013).\u003c/li\u003e\n\u003cli\u003eNinu, A. R. \u003cem\u003eEt al.\u003c/em\u003e Cesarean in mare by Marcenac incision under local anesthesia. \u003cem\u003eIran. J. Vet. Res.\u003c/em\u003e \u003cstrong\u003e16\u003c/strong\u003e, 117\u0026ndash;119 (2015).\u003c/li\u003e\n\u003cli\u003eMaaskant, A., Bruijn, C. M. De, Schutrups, A. H. \u0026amp; Stout, T. A. E. Dystocia in Friesian mares: Prevalence, causes and outcome following cesarean section. \u003cem\u003eEquine Vet. Educ.\u003c/em\u003e 190\u0026ndash;195 (2021).\u003c/li\u003e\n\u003cli\u003eRioja, E., Cernicchiaro, N., Costa, M. \u0026amp; Valverde, A. Perioperative risk factors for mortality and length of hospitalization in mares with dystocia undergoing general anesthesia: A retrospective study. \u003cem\u003eCanadain Vet. J.\u003c/em\u003e \u003cstrong\u003e53\u003c/strong\u003e, 502\u0026ndash;510 (2012).\u003c/li\u003e\n\u003cli\u003eBidwell, L., Embertson, R., Bone, N. \u0026amp; Ru, M. Diazepam levels in foals after dystocia birth. \u003cem\u003eProc. 54th Annu. Conv. Am. Assoc. Equine Pract. San Diego, California, December 6-10 2008.\u003c/em\u003e \u003cstrong\u003e54\u003c/strong\u003e, 286\u0026ndash;287 (2008).\u003c/li\u003e\n\u003cli\u003eSharma, A. \u003cem\u003eEt al.\u003c/em\u003e Dystocia due to breech presentation and cesarean under local anesthesia and sedation in a mare. \u003cem\u003eSVU-International J. Vet. Sci.\u003c/em\u003e \u003cstrong\u003e4\u003c/strong\u003e, 16\u0026ndash;21 (2021).\u003c/li\u003e\n\u003cli\u003eDutt, R. \u003cem\u003eEt al.\u003c/em\u003e Surgical management of dystocia due to fetal deformity in a mare. (2020).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Addis Ababa University, College of Veterinary Medicine and Agriculture, Bishoftu Ethiopia","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":" Cesarean section, Dystocia, Jenny, Pelvic deformity, Surgical approaches","lastPublishedDoi":"10.21203/rs.3.rs-5035757/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5035757/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Jenny dystocia occurs very rarely and is mainly associated with postural defects due to long fetal extremities. However, the management of dystocia in equines is relatively difficult compared to that in other large animals. Due to the absence of well-described published papers on cesarean section in donkeys, this condition can be life-threatening after unsuccessful surgical intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient presentation:\u003c/strong\u003e A 4-year-old Jenny with a difficult birth due to a previous car accident presented for 3 consecutive years at different stages of labor onset. Up on early presentation, there was straining and frequent aggressive rolling. Further examination also revealed a fully dilated cervix and narrow pelvic cavity due to the downward bending of the iliac wing. Surgical sites (lower flank, ventral midline, and paramedian) were used for each delivery. General anesthesia was used in all three procedures, and local infiltration of 2% lidocaine along with light general anesthesia was used at the time she presented with a live fetus. Surgical sites aseptically prepared for cesarean section and dead fetuses were removed at the 1\u003csup\u003est\u003c/sup\u003e and 3\u003csup\u003erd\u003c/sup\u003e parity due to delayed presentation. However, on the 2\u003csup\u003end\u003c/sup\u003e parity, a live female foal was delivered. In all the approaches, the 1\u003csup\u003est\u003c/sup\u003e layer of uterine closure was made by using a simple continuous suture pattern (biting all the layers of the uterine wall). Then, the sutures were oversewed with a Cushing suture pattern using #0 polyglycolic acid (PGA). The skin was closed by different suture patterns during each technique using nonabsorbable suture material # 1 silk. Postoperative subcutaneous swelling was observed and regressed gradually in all the approaches. The duration of skin suture removal was determined based on the extent of wound healing and the site of the incision.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: This is the first ever-identified surgical case in a donkey. Thus, this study was able to indicate different approaches for cesarean section in equines. Moreover, due to the bleeding nature of the equine uterus, simple continuous suturing was the pattern of choice for 1\u003csup\u003est\u003c/sup\u003e layer uterine closure. It was also concluded that subcutaneous edema is unavoidable in donkeys.\u003c/p\u003e","manuscriptTitle":"Multiple Cesarean Section Jenny","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-09 09:55:11","doi":"10.21203/rs.3.rs-5035757/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ebdf1306-5446-4347-b6bc-1398732dd5eb","owner":[],"postedDate":"September 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":37131558,"name":"Large Animal Medicine"}],"tags":[],"updatedAt":"2024-09-09T09:55:11+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-09 09:55:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5035757","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5035757","identity":"rs-5035757","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}