Cesarean Section in Buffaloes

A Cesarean section (c-section) is in many cases performed as a surgical emergency in buffaloes presented with dystocia, where fetal delivery by other obstetrical procedures fails or seems difficult. The fetotomy/c-section dilemma has been based on poor dam survival rates and poor fertility [1] with caesarean section, however, many reports indicated that dam survival was high when the surgery was performed early without previous handling [2-6], therefore an early decision to perform a c-section greatly improves dam survival. Although the surgery is an age-old procedure being widely performed in many locations, the technique has been poorly described in buffaloes. Newer anesthetic combinations for buffaloes have been described, largely improving patient’s safety and with little side-effects on the fetus, however; their use for c-sections in buffaloes is uncommon. In this chapter, the authors describe the c-section procedure in buffaloes including indications, preoperative preparation, operative sites, anesthesia, operative technique, post-operative care, operative and post-operative complications, dam survival, and future fertility of dams.

1. History

Although dystocia has been recorded in buffaloes as early as 1928 [7], the first recorded documentated c-section in buffalo appears to be that of Reddy, et al. [8], a few other reports are also available from the 1960s [9,10]. C-section in cattle had been reported as early as the 18th century [11,12], however, the earliest reports of c-section in cows in India; the major buffalo-rearing country, appeared in 1930 [13]. It is possible that buffalo c-sections were performed earlier as for cows, although no reports could be traced in the literature. The technique appears to be most frequently reported since the 1970s (in India) after which time, many case reports and clinical analyses have become available in the literature. Reports of the surgery being performed in buffaloes in other countries are usually not traceable although they are known to be performed.

2. Indications

Difficult births in buffaloes have been recently reviewed in terms of maternal [14], and fetal [15] causes, however, the indications for c-section in buffaloes was not the focus of these critical reviews. A few retrospective clinical studies [16-20] documented the many reasons of dystocia for which a c-section had to be performed in buffaloes. A large number of maternal and fetal reasons for which c-sections were performed, have been documented in buffaloes (Table 1).

It appears from these and a large number of retrospective clinical studies that mentioned the etiology, surgical approaches and outcome of therapy for uterine torsion in buffaloes [2,3,6,28-30,64], that the predominant reason for which c-section is performed, is uterine torsion of long duration and unable to correct by rolling of the dam.

Fetal monsters frequently pose difficulty in vaginal delivery due to feto-pelvic disproportion and thus require c-section for their delivery. Fetal monsters appear to be the second most common cause for which c-section is performed in the buffalo (Table 1). Fetal abnormalities like hydrocephalus, ascites and anasarca constitute the third largest cause for which c-section is performed (Table 1).

Fetal maldispositions are a less frequent indication for caesarean section in the buffalo. In a recent analysis of 112 cases of bubaline dystocia [15], 35.7% cases were due to fetal maldisposition, however, in this and previous reports [16,19] most fetal maldispositions in the buffalo could be corrected manually and/or by fetotomy, and only very few cases required a c-section.

Cervical dilation failure appears to be extremely low in the buffalo. Previous analyses reported 4/17 [16] and 1/20 [19] c-sections in buffalo being performed for this reason. A c-section due to fetal emphysema of long standing duration is potentially life-threatening and is considered as a last resort [4,61]. Similarly, hydroallantois, hydroamnion and macerated fetus are poor surgical risks for performing the operation due to poor dam survival. Less frequent indications for c-section include pelvic fractures, removal of macerated and mummified fetus. Elective c-sections are seldom if ever performed in the buffalo and cesarean is mostly an emergency surgery.

3. Preoperative Preparation

Preoperative preparation includes assessment of hematologic and blood chemistry values and administration of sufficient fluid replacements, antibiotics and corticosteroids as required [65]. Elevated concentrations of cortisol and histamine with alterations in total leukocytic, neutrophilic and lymphocytic counts have been reported in buffaloes presented with a dystocia [66]. Respiratory alkalosis has been documented in buffaloes with dystocia and uterine torsion [67,68] that underwent c-section [69]. Buffaloes with uterine torsion showed normocytic normochromic anemia and leukocytosis accompanied by neutrophilia and monocytosis [70]. Biochemical analysis revealed significant (P<0.01) changes in the plasma levels of AST, LDH, glucose, insulin, total protein, albumin, blood urea nitrogen (BUN) and creatinine in affected buffaloes compared to the control [71-73].

Following uterine torsion and after its correction by detorsion or surgical treatment, the liver functions are affected [18,73-77], which usually are stabilized within 10 days after surgical treatment. When a uterine torsion case is presented with a substantial increase in plasma urea and creatinine, the prognosis is poor [73]. In a uterine torsion, the ureters lying in the broad uterine ligaments are constricted and the urine output is decreased, and renal functions may be affected [78]. It is important to monitor the general condition of the buffaloes and institute therapy as required.

Buffaloes are susceptible to complications associated with recumbency of anesthesia including tympany, regurgitation and aspiration pneumonia. Accordingly it is suggested that buffaloes should be fasted for 12-18 h and deprived of water for 8-12 h before surgery, however, since most c-sections in buffaloes are performed on an emergency basis, fasting the animals is usually not possible. Glycopyrrolate (0.005-0.01 mg/kg IM or 0.002-0.005 mg/kg IV) has been suggested in cattle to prevent salivation during anesthesia [79]. Studies on buffalo calves that were administered 0.01 mg/kg IM of glycopyrrolate revealed a reduction in oral secretions with dry muzzle, mouth and nostrils within 41.5±3.34 min of administration and a significant increase in pulse pressure but without significant variation in heart rate and mean arterial pressure [80]. The use of glycopyrrolate was suggested in the buffalo to reduce the oronasal secretions.

4. Restraint

The restraint of animals for surgery depends on the surgical site used. In most c-sections performed on the left side, buffaloes are restrained in right lateral recumbency with both forelegs and both hind legs tied separately (with 2 ropes) (Fig. 1). In a ventrolateral approach, the surgeon can sit on small stool to perform the operation. In a paramedian approach, the animal is slightly tilted and the left hind leg is pulled more caudally to expose the operative site.

Figure 1. Restraint of a buffalo in right lateral recumbency for c-section through the left side.

5. Surgical Sites

Not all approaches mentioned for c-section in cattle [81] have been used in buffaloes, probably because a c-section is mostly performed in a recumbent buffalo due to a heavy capacious abdomen. The principal surgical site reported in most clinical studies is the left paramedian approach lateral and parallel to the milk vein (Fig. 2) (Table 2). In Iran, a similar site is commonly used for c-section in buffaloes [85]. A major flaw with most reports on c-section in buffaloes is the absence or a good description of the anesthesia and surgical procedures used (compare Table 1 and Table 2) preventing clear analysis of the surgical sites in different studies.

Figure 2. The paramedian operative site for c-section in the buffalo (dotted line).

Left oblique ventrolateral site (above the arcus cruralis) is the second commonly used operative site for c-section in buffalo (Table 2) (Fig. 3) and considered by a few surgeons as a better operative site [6,16,19,23] due to lesser post-operative complications and minimum contamination of the operative site during sternal recumbency. Flank laparotomies (Fig. 4) are not commonly used for c-section in the buffalo.

Figure 3. The oblique ventrolateral operative site for c-section in the buffalo (dotted line).

Figure 4. The operative site on the left paralumbar fossa in the buffalo (dotted line).

Only one retrospective clinical study on buffalo c-sections compared the complications of c-sections performed employing different operative sites, and suggested that the midline and paramedian operative sites resulted in more postoperative complications like wound dehiscence and hernia due to the heavy weight of abdomen resting on the suture line [16] and this was the only report which depicted the use of midline site for c-section in the buffalo. This approach is seldom used in buffalo due to difficulty in patient positioning during surgery.

6. Anesthesia in Buffaloes

Most c-sections in buffaloes are an emergency and can be satisfactorily performed under local infiltration analgesia using 2% lidocaine. Vicious buffaloes may require some sedation using triflupromazine, chlorpromazine or xylazine. The anesthetic management of cattle has been mentioned in detail including drugs used for sedation, induction and maintenance of anesthesia [86]. Descriptions on a large number of sedatives, induction agents and general inhalation anesthetics have appeared during the last few years for buffaloes and are mentioned here for reference.

6.1. Chloral Hydrate

An anesthetic mixture used in early studies comprised of chloral hydrate (30 g), magnesium sulfate (15 g) and thiopental (2.5 g) in 1000 mL of distilled water [87] administered IV at 2.0 mL/kg. This was administered 30 min after SC administration of atropine. In another previous report chloral hydrate alone at 102 mg/kg IV or combined with thiopental sodium (1 g/200 kg) was administered to buffalo calves [88]. Earlier reports also depicted oral administration of chloral hydrate in jaggery [36]. These combinations produced marked cardiopulmonary effects and hence are no more used in most bubaline c-sections. Chloral hydrate alone is known to result in a significant tachycardia, moderate transient hypotension and a significant fall in central venous pressure with significant alterations in acid base balances [88] and hence its use is not suggested.

6.2. Xylazine

Xylazine is known to cause marked sedation in the buffalo species with increased salivation, regurgitation and bradycardia at dose rates of 0.22 and 0.44 mg/kg administered IV or 0.44 mg/kg administered IM [89,90]. Recovery time with xylazine is prolonged (150 min) with an IM administration [91]. The administration of 0.04 mg/kg of atropine IM before xylazine administration reduces salivary secretions and bradycardia [89], however, lower IM dosage of 0.10 to 0.15 mg/kg have been suggested in one study on buffalo calves [92] and in a recent study [93], a dosage as low as 0.04 mg/kg in combination with 0.04 mg/kg atropine sulfate have been suggested to be satisfactory. The sedative effects of xylazine can be reversed within 15 min by IV administration of yohimbine (0.125 mg/kg) or atipamezole (10 μg/kg) [94]. Xylazine may increase uterine tone, increase secretions, increase the risk of aspiration pneumonia, and lead to ataxia so it must be used carefully in the buffalo [95,96].

6.3. Triflupromazine

Both triflupromazine and chlorpromazine have been used for sedation of buffaloes for c-section [22,24,30,42,84]. triflupromazine administered at the dose rate of 5 mg/100 lb to buffalo calves produced sedation within 10-30 min of an IM injection and the effect lasted 70-180 min with minimal cardiac and respiratory suppression [97]. Combination of triflupromazine (0.3 mg/kg IM) followed 10 min later by IV administration of romifidine (10 μg/kg) and ketamine (5 mg/kg IV) produced satisfactory anesthesia in buffalo calves for 14±2.3 min whereas romifidine alone (10 μg/kg) resulted in rapid onset and sedation for 31±4.8 min [98].

6.4. Ketamine

Ketamine (2.0 mg/kg IV) has been combined with chlorpromazine (2.0 mg/kg IM) to anesthetize water buffalo calves. Pretreatment with chlorpromazine increases the duration of analgesia and recovery time beyond that achieved with ketamine alone. However, such combinations are suited for short-term surgical procedures of 5 to 10 min [99] and thus not suitable alone for c-section in buffalo.

6.5. Detomidine and Medetomidine

Detomidine (40 μg/kg) administered IM produces marked ataxia and sternal recumbency in buffalo calves (85-140 kg weight) within 10 min of injection and complete recovery occurs in 90 min [100]. However, marked bradycardia is observed for the first 60 min of injection [101]. Administration of medetomidine (10 μg/kg IV) and romifidine (50 μg/kg) produced moderate sedation, mild muscle relaxation and mild analgesia in buffalo calves with romifidine resulting in marked cardiopulmonary depression compared to medetomidine [102]; the drugs were considered safe for clinical examination only. In recent years these drugs have been used in varying amounts as sedatives or induction agents during anesthesia in buffaloes.

6.6. Propofol

The IV administration of propofol (4.0 mg/kg) resulted in sternal recumbency in buffalo calves within 25±3 s, however, this dose produced only cutaneous analgesia with complete recovery in 39±3 min [103]. Propofol at dosage of 3.0 mg/kg has been recently suggested as a safe and rapid agent for induction of anesthesia that produced satisfactory conditions for endotracheal intubation for inhalation anesthesia [104].

6.7. Guaifenesin

Guaifenesin has been considered as a muscle relaxant in buffalo calves [105], however, the use of guaifenesin (165 mg/kg IV) alone in water buffalo calves to produce complete immobilization causes significant hypotension. Cardiovascular and respiratory depressant effects produced by high doses of guaifenesin are generally undesirable [106].

6.8. Short Term Anesthesia

Various combinations for short term intravenous anesthesia have been experimented in the buffalo. In one study, adult male buffaloes were administered medetomidine (2.5 μg/kg) and butorphanol (0.05 mg/kg) intravenously as preanesthetics. Anesthesia was induced with 5% thiopental and maintained by continuous IV infusion of either ketamine (1%) or propofol (1%). Anesthesia could be successfully maintained for up to 2 h with propofol producing some cardiopulmonary depression [107]. Other combinations suggested include combinations of triflupromazine-romifidine and ketamine [83], medetomidine and ketamine [108], or detomidine, diazepam and ketamine [109].

6.9. Inhalation Anesthesia

Earliest mention on the use of inhalation anesthesia in buffalo calves using chloroform with oxygen and nitrous oxide following induction with thiopental sodium (22 mg/kg IV) and premedication with triflupromazine (15 mg/100 kg IM) was reported in 1972 [110], however, due to serious hepatotoxicity with chloroform its further use was discontinued. Reports on the satisfactory use of long lasting inhalation anesthesia in water buffaloes have appeared in the literature [104,111-114], however, their use is dictated by the availability of proper facilities and delivery equipment which are currently unavailable at most bubaline obstetric clinics. Moreover, the cost of anesthetics limits their use for water buffaloes. Endotracheal intubation in the larynx is required to provide a safe airway and prevent aspiration of salivary and ruminal contents if passive regurgitation occurs [86]. One study on the use of inhalation anesthesia evaluated fentanyl (5 μg/kg IV) and medetomidine (2.5 g IV) as preanesthetic and 5% thiopental as induction agent with anesthesia being maintained by 2% halothane or 2% isoflurane [113]. None of the drug combinations produced deleterious effects on the vital organ functions and cardio-pulmonary functions were well preserved. The same authors also evaluated and found that fentanyl-dexmedetomidine-thiopental-isoflurane and fentanyl-medetomidine-thiopental-isoflurane produced effective safe surgical anesthesia in water buffaloes and cardiopulmonary functions were well preserved with these combinations [114]. In another study medetomidine (2.5 mg/kg IV) and butorphanol (0.05 mg/kg IV) used as premedication and anesthesia induced by 5% thiopental sodium and maintained with halothane produced better sedation, analgesia and muscular relaxation (safely maintaining anesthesia for 2 h) compared to when buffaloes were premedicated with midazolam (2.5 mg/kg IV) and butorphanol (0.05 mg/kg IV) [115].

6.10. Spinal Anesthesia

The use of spinal anesthesia has been documented in some reports on c-section in buffaloes. The most common spinal anesthesia used is paravertebral nerve block and to a limited extent epidural anesthesia.

6.10.1. Paravertebral Nerve Block

The earliest available report on the use of paravertebral nerve block in buffaloes appeared in early 1970 [22,35,116]. The anesthesia involves regional deposition of local anesthetic around spinal nerves (13th thoracic, 1st and 2nd lumbar nerves) and its use has also been documented in later reports on c-section in buffaloes (Table 2). The dosage of local anesthetic deposited at these sites varies from 10 mL [35] to 20 mL [116] of 2-4% novocaine or lidocaine. Recently, it has been claimed that local anesthetic was reduced to 5 mL of 2% lidocaine when the anesthesia was placed safely by ultrasound-guided technique [117].

6.10.2. Epidural Anesthesia

The earliest documentation of epidural anesthesia using 2% lidocaine appears to be that of Lyatifov [118] suggesting that the local anesthetic be deposited in the intercoccygeal space between last sacral and 1st and 2nd coccygeal vertebra, which produces anesthesia of hindquarters. This becomes evident by loss of sensibility in the tail which becomes flaccid within 2-3 min of administration. A variety of local anesthetics and sedatives have been tested in buffaloes to achieve safe spinal analgesia [119-123], however, since these approaches are seldom used for c-section in the buffalo [124], their detailed description will not be mentioned here.

7. Operative Procedure

The usual operative procedures necessary for surgical interventions should be followed. The detailed description on the surgical technique has been recently mentioned [65]. Briefly, the operative site is prepared by shaving and scrubbing, and local infiltration anesthesia is infused at the operative site using 60-80 mL of 2% lidocaine or lignocaine. The skin is incised and separated from the subcutaneous layer (Fig. 5, Fig. 6). The muscles are then incised ligating all the bleeding vessels. The assistant should hold the muscle layers with tissue holding forceps and the surgeon should cut the muscles (Fig. 7). The peritoneum which is a glistening white layer (Fig. 8), is cut by first making a nick with scissors and then guiding the cut by a finger placed underneath the skin. The attachment of the muscles is cut when using the ventrolateral approach. The omental fat sometimes covers the uterus which is pushed to the side or sometimes incised. The uterus is located and brought to the operative site by holding the uterus over a fetal leg (Fig. 9). The uterus is packed on the sides by surgical drapes (Fig. 10). The uterus should be incised away from the cervix over the greater curvature avoiding the cotyledons. In long standing cases of dystocia or uterine torsion sometimes it is not possible to bring the uterus to the operative site and under such conditions the uterus has to be incised in the abdominal cavity. The fetus is removed as quickly as possible (Fig. 11, Fig. 12) and the margins of the uterus are washed with sterile normal saline. Removal of parts of the necrosed/ischemic uterus is suggested [125] for the rest of uterus to regain normal function. When the placenta has completely separated, it usually remains attached to the fetus and is removed along with the fetus. In some cases, placenta remains attached to only a few caruncles and it can be separated quickly. In all other cases, it should be left in situ with no attempt to remove by traction as caruncular detachment may occur. Before suturing, uterus should always be examined for a second fetus.

Figure 5. Skin incision in a buffalo (oblique ventrolateral approach) during c-section.

Figure 6. Skin incision in a buffalo (paramedian approach) during c-section.

Figure 7. Incision on the muscles by holding with tissue forceps.

Figure 8. Incison of the peritoneum which is visible as a glistening white membrane.

Figure 9. Bringing the uterus up to the operative site by grasping a fetal extremity.

Figure 10. Packing of the uterus with sterile surgical drapes.

Figure 11. Fetal delivery after uterine incision during c-section in a buffalo.

Figure 12. Delivery of an emphysematous fetus after uterine incision during c-section in a buffalo.

The uterus is sutured using either natural (Chromic catgut 2/0 or 3/0) or synthetic absorbable suture materials (Polyglycolic acid 2/0) employing Lambert, Cushing [1,126] or Utrecht inversion suture pattern as described for cattle [81]. If tears in the uterine wall ruptures are detected it is desirable to inject 20-40 IU of oxytocin in the uterine wall to reduce the uterine size. The uterus is replaced back in the abdomen after thorough washing. Shreds of tissue debris and contaminants that can inadvertently enter the peritoneum should be removed by infusing the peritoneal cavity with normal saline and scooping out the contents manually or by using suction apparatus. Placement of antibiotic pessaries inside the uterus before its final closure has been suggested [1]. The muscle and peritoneal layers are sutured using the same suture material and employing continuous suture pattern. Sometimes, interrupted sutures may be used. It is often beneficial to sprinkle antibiotic powders between the suture layers especially while removing an emphysematous fetus. The skin is sutured employing simple or mattress interlocking interrupted sutures using silk (Fig. 13). Needle holders and curved needles should be sufficiently strong for suture of buffalo skin which is very thick. A sterile dressing is applied over the suture line (Fig. 14) and this should be protected by applying a cloth over the abdomen.

Figure 13. Skin sutures in a buffalo during c-section.

Figure 14. A sterile dressing applied over skin sutures in a buffalo that underwent c-section.

8. Suture Material

Suture materials play an important role in wound repair by providing support for healing tissue. Descriptions on the efficacy of different suture materials in buffaloes are scarce [127,128] and most descriptions are available from studies in cattle. An ideal suture material should have good handling characteristics, knot security and tensile strength. It should be sterile, non-electrolytic, non-capillary, non-allergenic, non-carcinogenic and should not provide a medium for bacterial growth [129]. Most commonly, absorbable suture materials like chromic catgut are used to close the uterine incision during c-section. Plain catgut is a natural, absorbable, multifilament suture material prepared from purified connective tissue derived from either the submucosa of sheep intestines or the serosal layer of bovine intestines. Plain catgut produces a moderate inflammatory reaction in tissue as it is broken down through a combination of enzymatic degradation and phagocytosis. The rate of absorption of catgut is increased in the presence of infection and in tissues with high levels of proteolytic enzymes [130]. However, chromic catgut reduces the soft tissue reaction and the rate of absorption. But chromic catgut has certain disadvantages: it is difficult to handle, has a tendency to fray and has poor knot security when wet [131]. On the other hand, synthetic absorbable suture materials like polyglactin-910 or polyglycolic acid have also been put into use to suture the uterine incision during c-section in bovines. Polyglactin-910 is made from co-polymer of 90% glycolide and 10% L-lactide. It elicits minimal inflammatory reaction and is absorbed through hydrolysis [129]. With good handling characteristics and size to strength ratio, it may be used in a variety of tissues, including infected wounds [132]. Another synthetic suture material, Polyglycolic acid, a braided multifilament suture material made from synthetic polyester polymerized from hydroxyacetic acid [132] has also been recommended in cesareans to close uterine incision [133]. Polyglycolic acid is absorbed by hydrolysis and rapidly loses its tensile strength. Tissue reaction from the absorption of this material is considerably less than that encountered with plain catgut, and the by-products of hydrolysis do not provide a growth medium for bacteria [134]. Higher dam survival rate and less peri-uterine adhesions were observed in buffaloes in which the uterus was sutured with polyglycolic acid rather than with chromic catgut [127]. However, it is very likely that chromic catgut continues to be used in most obstetric referral centers where buffalo c-sections are performed as the most commonly used suture material due to its easy availability, although its use may be restricted in some countries by the food and drug authorities.

9. Post-operative Care

The success of the surgery depends upon the post-operative care. Dystocia affected buffaloes undergoing c-section suffer from variable degrees of dehydration and toxemia [135]. Plasma and blood volumes usually remain significantly lower in buffaloes undergoing c-section than in the normally calved ones [135]. If an animal is off feed for 72 hours, post-operative peritonitis should be suspected. The endotoxic shock may be the ultimate stage as a consequence of dystocia and peritonitis following a cesarean section. The primary treatment for endotoxic shock is plasma volume expansion to maintain adequate tissue perfusion [136]. Isotonic saline solutions are preferred over hypertonic solutions to expand plasma volume [137]. About 5-10 L of normal saline solution should be administered for 3-5 days post-cesarean to combat dehydration and toxemia [138]. Sufficient antibiotics and anti-inflammatory drugs should also be given for 5-7 days to combat toxemia. Sterile procaine penicillin G 22000 U/kg IM every 24 h for 5-7 days or oxytetracycline 10-20 mg/kg IM daily for 3-7 days is satisfactory. Combinations of ampicillin and cloxacillin 5-10 mg/kg IM or IV, every 12 h for 5-7 days have yielded satisfactory results in most caesarean sections in buffaloes. It is suggested to use this combination together with an IV infusion of metronidazole (10 mg/kg) in the presence of an emphysematous fetus or when peritonitis due to contamination of the abdominal cavity during surgery is suspected [138]. Based on study of uterine tissue concentrations after single IV infusion of 5 mg/kg of neomycin and the drug clearance, the dose of neomycin suggested for dystocia affected buffaloes was 3-5 mg/kg IV followed by 2 mg/kg IV [139]. Meloxicam (0.25 mg/kg IM) or a combination of phenylbutazone (10 mg/kg) and sodium salicylate (1 mg/kg) are suggested to be administered IM daily for 5 days to minimize inflammation and thus prevent adhesion formation. The use of methylergometrine maleate (5-10 mg IM) is suggested if postoperative uterine bleeding is noticed. It is better to administer broad spectrum antibiotics along with drugs like metronidazole to combat possible anaerobic infections. The surgical site should be cleaned daily.

Antihistaminics, multivitamins and rumenotorics may be given along with other drugs as needed. The skin sutures can be removed 10-12 days post-cesarean section.

10. Surgical Complications

The possible complications seen during a c-section in buffaloes include:

• Excessive bleeding of the abdominal wall. Careful hemostasis should prevent the formation of hematoma in the abdominal wound.
• Excessive trauma to the uterine wall or the broad ligaments may induce fatal bleeding.
• Bleeding from the uterine incision may occur if placentomes are accidentally cut or damaged.
• Impossible exteriorization of the uterus from the abdominal cavity may be observed due to adhesions resulting from previous surgical interventions or irreducible uterine torsion.
• There can be a serious risk for sudden exteriorization of the rumen during a bout of straining. Therefore, one should always keep a close eye on the abdominal wound from the moment peritoneal cavity is opened until the calf has been delivered.

11. Postoperative Complications

The major complications following a c-section in buffaloes include:

11.1. Peritonitis

Severe peritonitis may develop following c-section due to either exogenous (leakage of uterine fluids through the uterine wound, the rupture of the suture material or knotting failure of continuous uterine suture) or endogenous bacterial flora. At the time of the c-section in buffaloes, the most common organisms in uterine fluid samples were E. Coli (26.5%), Pseudomonas sp. (15.0%) and Proteus sp. (15.0%). Other bacteria found in decreasing order of occurrence were Arcanobacter pyogenes, Staphylococcus aureus, Bacillus sp. and Klebsiella [140]. Various other reports have also described E. coli as the most common isolate in the uterus of buffaloes undergoing c-section [124,141]. The possible consequences of peritonitis are utero-omental and intra-abdominal adhesions that invariably lead to death or infertility [140]. In a recent study on 65 c-sections in buffaloes, 20/46 buffaloes operated on for uterine torsion developed peritonitis whereas 6/8 buffaloes operated for emphysematous fetus developed peritonitis, dam survival was 73.9% and 37.5% respectively [138], indicating that peritonitis is more likely with previous handling and hence an early intervention is suggested to minimize endotoxemia and improve dam survival.

11.2. Uterine Adhesions

Post-operative intra-abdominal adhesion formation is a potential problem following c-section in buffaloes. Adhesions are formed from fibrin deposition (fibrinous adhesions) produced in response to an insult to the peritoneum. Any peritoneal trauma results in serosanguineous exudate that contains two closely bound proteins: fibrinogen and plasminogen. Fibrinogen is converted by thrombin to fibrin, forming early fibrinous adhesions; plasminogen may be converted by plasminogen activators to plasmin, a specified fibrinolytic enzyme, favoring the lysis of early adhesions. Thus, under normal circumstances fibrin is lysed and absorbed but, in some cases, fibrin may remain and become invaded by fibroblasts, resulting in irreversible fibrous adhesions. Bovines are more likely to form fibrous adhesions than other species since they have very low levels of plasminogen activators and high levels of fibrinolytic inhibitors, which favor adhesion formation [142]. Uterine adhesions can be detected by trans-rectal palpation around 30-40 days post-cesarean in buffaloes [5]. Adhesions can disrupt reproductive processes and significantly impair fertility. Surgically-induced adhesions may result from several factors, including tissue ischemia [143], tissue trauma, exudation of proteinaceous fluid, improper hemostasis [144] and tissue reaction to foreign bodies such as suture materials [145]. Histopathological examination of uterine tissue at the time of c-section has shown mild to severe degenerative changes in buffaloes [127]. Epithelial/subepithelial changes (congestion, edema, thrombosis with variable degree of hemorrhage or intermuscular edema) (Fig. 15 A-D), sloughing of endometrial epithelium (Fig. 15A), endometrial glandular damage (Fig. 15B) and muscular damage (swelling, edema, degeneration, necrosis and disruption) (Fig. 15 C-E) occur at the time of c-section in buffaloes [126].

Figure 15. Alterations in uterine tissue on the day of a c-section in a buffalo. (A) Superficial epithelial damage showing congestion, edema, necrosis and sloughing of uterine epithelium. (B) Mild endometrial glandular damage with sub-endometrial hemorrhage and congestion. (C) Thrombosis with severe endometrial congestion, hemorrhage, and muscular damage. (D) Presence of microthrombi with severe muscular disruption and necrosis. (E) Intramuscular edema with muscular damage and swelling of muscle fibers.

It has been clinically proven in buffaloes that the formation of post-operative adhesions is comparatively less with the use of polyglycolic acid suture material for closing the uterine incision compared to chromic catgut [146].

Another agent, sodium carboxymethyl cellulose (CMC) may also be used to reduce the formation of adhesions following c-section in buffaloes. Sodium carboxymethyl cellulose is a substituted polysaccharide which acts as a mechanical lubricating barrier between adjacent serosal surfaces, thereby preventing the formation of adhesions [147]. Solutions of CMC have decreased the frequency of adhesion formation after abdominal surgery in various species [5,148-151]. Intraperitoneal infusion of CMC (1 %, 14 ml/kg body weight) on the day of the c-section proved quite effective in reducing adhesion formations in buffaloes [146].

The severity of adhesion formation is directly related to the duration of dystocia. It has been documented that if dystocia is prolonged for more than 36 hours in buffaloes, then severe postoperative uterine adhesions are developed compared to fresh cases [152]. This can be due to more bacterial infection and fibrin clots in peritoneal cavity or mechanical insults that can probably occur over the uterus in animals having prolonged duration of dystocia. The mechanism by which infection induces adhesions has not been clearly established, however, bacteria release numerous enzymes that may damage tissues and produce substantial inflammatory exudates [153]. It has been established that the peritoneum after becoming ischemic loses its spontaneous ability to lyse fibrin [154]. Moreover, ischemic tissue also inhibits fibrinolysis by adjacent normal tissue [154]. In delayed cases of dystocia, the uterus become ischemic with time, therefore, the tendency of adhesion formation is more severe in these cases.

11.3. Delayed Uterine Involution

A marked delay in uterine involution is generally observed in buffaloes that underwent a c-section [127]. The characteristic signs may be observed on Days 30-40 post-caesarean. These include a big atonic uterus filled up with exudates and debris, deeply situated uterus in the abdominal cavity and increased quantity of lochial discharge. This may be attributed to severe trauma on the abdominal and uterine wall due to the incisions, manipulations and suturing at the time of the c-section. When peri-uterine adhesions develop in the ventral part of abdomen, the regression and involution of the uterus is severely affected [127].

11.4 Wound Dehiscence

Wound dehiscence is considered as one of the major disadvantages of the recumbent approaches for c-section. In spite of the administration of heavy anti-bacterial agents, a marked rate of wound dehiscence is recorded in buffaloes with a c-section [127]. In a recent study, however, only 5 of the 65 buffaloes that underwent a c-section, developed postoperative wound dehiscence [138]. Serum-like fluid accumulates at the ventral aspect of the surgical wound between the muscle layers if the dead space is not fully occluded [155]. This may be due to poor aseptic technique, inadequately sterilized equipment, and trauma to tissues during surgery, low abdominal incisions, early removal of skin sutures, aggressive temperament of animal, environmental contamination or poor management of surgical site by the owner [81,127].

11.5 Milk Yield

The effect of a c-section on milk production is difficult to interpret due to various factors [81]. In cattle, post-cesarean milk production is thought to be decreased by 80-1500 L compared with the previous lactation [156,157]. In buffaloes, few literature reports are available about the effect of a c-section on milk production. In one study, milk production was decreased by 75% compared to the previous lactation in buffaloes that had undergone more than one c-section [127].

12. Survival Rates and Future Fertility

One of the main goals of a c-section is to deliver a viable calf and to preserve the life of the dam. Dam’s survival rate was recorded at 36 to 100% following a c-section in buffaloes presented with a dystocia [1-4,14,16,19,20,23,34,37,127,140,158,159].

The time elapsed since dystocia onset and surgery is an important determinant of the outcome. Dam survival rates are high (64.7 to 100.0%) when surgery is performed within 24-36 h of dystocia onset [2-5,14], whereas, survival rate may decrease to 25–33% when surgery was performed after 72 h [3,4,20]. The total dam survival rates for 73 c-sections performed by practitioners in the field was 67.1% whereas for 102 c-sections performed at referral centers, dam survival was only 43.2%, probably because of prompt performance of the surgery by the practitioners compared to the delay in presentation of the animal to the referral centers [4].

Previous handling is an important factor that determines the outcome of surgery. In a few clinical analyses, the survival of buffaloes with a c-section was high (62-100%) for buffaloes with uterine torsion when surgery was performed without previous rolling [2,20,28], but decreased to 45-66% when uterine torsion affected buffaloes were operated on after previous rolling. The low survival rate observed in previously handled cases may be attributed to a higher degree of stress and severe metabolic disorders leading to peritonitis, septicemia, toxemia, shock and death in high proportion [127,160]. Presence of an emphysematous fetus also decreases post-cesarean survivability in buffaloes due to progression of endotoxemia [1,140,160,161].

Little information is available on fetal survival after a c-section buffaloes. Since most c-sections are performed as an emergency surgical procedure, frequently being performed to relieve uterine torsion or because of fetal monstrosities, fetal survival is expected to be low since the fetus is either abnormal or will die due to hypoxia. On 59 c-sections performed at one referral center, in buffaloes with a uterine torsion, only 2 live calves could be delivered [23]. Similarly, in another report only 6.1% live calves were delivered on 29 c-sections performed on buffaloes with a uterine torsion [6]. None of the monsters reported to be delivered by c-section in buffaloes (Table 1) was mentioned to have survived. Thus dam and fetal survival can be improved in uterine torsions if surgery is performed early before the onset of toxemia and fetal death.

The future fertility of buffaloes that underwent a c-section has been and continues to be a matter of concern for clinicians and farmers alike; however, very few reports have addressed this issue in buffaloes. According to one report, 27.7% of buffaloes conceived after a c-section [4], whereas, another report has documented that 37.5% of buffaloes conceived after a c-section. Information on 12.5% of buffaloes could not be traced due to animals having been sold [19]. A recent study [1] observed nearly similar conception rates of 36.3% for 63 buffaloes that underwent c-section [1].

The future fertility of the animal depends upon the state of uterine health at the time of surgery. A reliable indicator for future fertility of animals that underwent a c-section is the elasticity of the uterus diagnosed by transrectal palpation. A tout uterus which cannot be manually depressed will definitely indicate low subsequent fertility. Buffaloes in which the duration of dystocia was more than 12 hours and buffaloes with a dead fetus at the time of surgery, will have lower subsequent fertility [127].