Health & Management / Ruminants Pain Management / Techniques and protocols OVERVIEW:
Pain Prevention for Caesarean Section in Ruminants:
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Introduction and General Information

Caesarean section is a surgical procedure which is required when delivery of the fetus or fetuses per vaginum is not possible. The ideal outcome of caesarean section is a live, undamaged dam able to rear her offspring, and live offspring. (J15.22.w2)

The traditional surgical approach for caesarean section in ruminants is that of a left flank laparotomy. A left paramedian approach is an alternative which may be used in sheep. (J15.22.w2)

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Reasons for the procedure

  • Caesarean section is indicated in fetal or maternal dystocia. (B217.69.w69)
  • Caesarean section is needed in about 1% of cases of dystocia in sheep. (J15.22.w2). 

    Conditions in which caesarean section is indicated include:

    • Failure of the cervix to dilate;
    • Malpresentation which is not reducible;
    • Fetal oversize / feto-maternal (feto-pelvic) disproportion;
    • Abnormalities of the fetus e.g. conjoined twins, fetal monster;
    • Large lamb in posterior presentation;
    • Abnormalities of the genital tract of the ewe, including e.g. known existing pelvic fracture;
    • Severe vaginal prolapse where vaginal delivery is likely to make existing traumatic damage worse;
    • Emphysema of the fetus;
    • Irreducible uterine torsion.

    (B354.20.w20, J15.21.w4, J15.22.w2)

  • Caesarean section may be carried out as a therapeutic measure in ewes with pregnancy toxamia. (B217.69.w69, J15.22.w2)
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Arguments against use of the procedure

  • Breeding cows such that a caesarean is likely to be required should be avoided on welfare and ethical grounds. (B344.55.w55, B354.20.w20)
  • Embryotomy may be preferable to caesarean section for grossly infected (putrid) fetuses; success of caesarean section is greatly reduced in these circumstances, in comparison to cases where the fetus(s) are alive or freshly dead. (B354.20.w20, J15.21.w4)
  • Caesarean section may not be an appropriate option for a ewe in advanced pregnancy toxaemia presenting with life-threatening biochemical abnormalities such as severe uraemia. (J15.22.w2)
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Signs/Evidence of pain associated with the procedure

  • It is generally accepted that surgical procedures such as caesarean section are painful. (J284.71.w1, P61.62.w1, J303.10.w1, J303.12.w1)
    • A survey of cattle veterinary practitioners (postal questionnaire to members of the British Cattle Veterinary Association) found that on a scale of 0 (no pain) to 10 (high pain), most practitioners scored post-operative pain for caesarean section at 5 to 8. (J303.8.w1)
    • A survey of veterinarians in cattle practice attending a BCVA meeting found that on a scale of 0 (no pain to 10 (high pain) caesarean section was given a mean score of 5.6, median 6 and inter-quartile range 4-7. The respondents generally scored post-operative pain from caesarean section lower than pain due to lameness associated with either solar ulcer or foul-in-the-foot. (J303.10.w1)
      • In the opinion of the authors of the paper, it is likely that when local anaesthetics have worn off pain "lasting some time" will be experienced by the individual on which a caesarean section has been performed. (J303.10.w1)
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Suggested methods of pain prevention

Some form of analgesia is required when carrying out this surgical procedure.
  • "Surgical operations such as laparotomies must be performed with excellent anesthetic techniques." (B207.2.w2)

General anaesthesia:

  • In sheep general anaesthesia may be used, for example using Saffan (alfadalone/alfaxalone), or halothane. (B217.69.w69)
    • This provides good relaxation and anaesthesia, and avoids any risk of unexpected movements of the animal during the procedure. (J15.21.w4)
    • There are always risks associated with general anaesthesia in ruminants, particularly since usually it is not possible to starve the animal before undertaking the caesarean section. (J15.21.w4)

Local or regional anaesthesia:

  • Paravertebral block, inverted L block or line block may be used for a flank approach in cattle. (B356.14.w14)
  • High epidural block (lumbosacral epidural), inverted L block or line block may be used for a paramedian approach in cattle. (B356.14.w14)
  • Paravertebral block of spinal nerves T13, L1, L2 and L3 is recommended in cattle. (B344.66.w66)
  • Paravertebral block, lumbosacral epidural or local infiltration at the incision site may be used in sheep. (B217.69.w69)
  • Additional epidural anaesthesia (in association with a local anaesthetic technique) is useful to prevent straining, and possible prolapse of organs through the incision, during the procedure. (B344.66.w66, B354.20.w20, J15.21.w4)
  • Inverted L block may be used; it is relatively quick and easy to administer, is effective rapidly and does not interfere with the ewe standing and mothering her lambs. (J15.21.w4) See: Inverted L Block in Ruminants
  • Line block should be avoided if possible for flank laparotomy. (B344.66.w66) See: Line Block in Ruminants
  • Epidural analgesia:
    • Epidural using lidocaine provides adequate flank anaesthesia but usually also causes recumbency, which may be prolonged in cattle. (B354.20.w20)
    • Both lumbosacral and sacrococcygeal epidural using xylazine 0.07 mg/kg made up to a volume of 2.5 ml in sterile water have been used to provide surgical analgesia for caesarean section (left flank incision) in the ewe. A period of 40 to 50 minutes was allowed between injection and testing by skin-prick followed by incision. Following lumbosacral epidural injection, analgesia was considered good in five ewes and adequate in three ewes, while one ewe required additional local anaesthetic line block. Following sacrococcygeal epidural, injection analgesia was considered good in 12 ewes, with one ewe requiring additional local anaesthetic. The failure of epidural anaesthetic in two ewes was considered likely to be due to incorrect injection. No sedation was noted in any of the ewes following epidural xylazine injection. Hind limb ataxia persisted for up to eight hours. This may cause practical problems with husbandry, including inability of lambs to suck colostrum from the udder while the ewe is recumbent. (J35.154.w3)
    • See: Caudal Epidural Anaesthesia of Cattle, Caudal Epidural Anaesthesia in Sheep, Lumbosacral Epidural Anaesthesia in Sheep and Goats

For post-surgical analgesia:

  • Caudal epidural anaesthesia with 1.75 ml lidocaine plus 0.25 ml 2% xylazine for a 75 kg ewe is particularly useful for controlling straining and in individuals where posterior reproductive tract damage has occurred. (J15.21.w4)
  • NSAIDs such as carprofen, flunixin meglumine and ketoprofen are useful in any cases where the ewe has bruising or swelling as well as in individuals which are toxaemic. (J15.21.w4)
  • It is suggested that a NSAID should be given routinely preoperatively, e.g. ketoprofen 3 mg/kg intravenously or carprofen 1 mg/kg intravenously as part of preparation for caesarean section in sheep and that further post-operative analgesia may not then be required. Note: these products are not licensed for use in sheep in the UK: "The cascade principle applies and a 28-day meat withdrawal period must be observed. (UK).(J15.22.w2)
  • Use of a NSAID should be considered following caesarean section in cattle, (J303.12.w1) particularly in individuals where severe dystocia, uterine torsion or uterine infection was present prior to surgery. (B354.20.w20)
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Reasons why adequate pain relief is not always provided

Reasons why adequate pain prevention may not be provided are described in detail in: Reasons for Failure to Provide Pain Relief. In brief, these include:

  • Attitudes towards pain in animals;
  • Tradition;
  • Failure to recognise pain;
  • Failure to recognise the importance of the adverse effects of pain;
  • Concern about removing possible protective effects of pain [this concern is generally excessive];
  • Concern that providing pain relief may itself stress the animal and have a negative impact on it;
  • Concern that treating pain may interfere with diagnosis;
  • Lack of information about analgesics;
  • Concern about toxicity and side-effects of analgesics;
  • Concerns about the safety and legislative controls associated with some analgesics such as opiates;
  • Economic and practical considerations.
Specific published reasons for failure to provide pain relief for caesarean section are indicated below.

Failure to recognise pain:

  • It is unlikely that caesarean section would be undertaken without provision of analgesia; it is usually carried out under local anaesthesia with or without sedation. However the effects of local anaesthesia last only a few hours and it is likely that after this time pain lasting for some time will be experienced. (J303.10.w1) Use of post-surgical analgesia may not be considered for a variety of reasons.
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Authors & Referees

Authors Dr Debra Bourne MA VetMB PhD MRCVS (V.w5)
Referee A.B.Forbes BVM&S.,CBiol.,MIBiol.,DipEVPC.,MRCVS (V.w66)

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