obstetrical conditions of domestic animals.pptx

gynecology and obstetrics in farm animals

1. Helpful in confirming a diagnosis and also confirming the viability of calf, particularly at certain stages of pregnancy Felt in the middle uterine artery, which supplies blood to foetus Enlargement of the uterine artery ipsilateral to the pregnant horn is detectable after 80 to 90 days of gestation By 120 days of pregnancy the middle uterine artery will have enlarged sufficiently to be used as a differential diagnosis in pregnancy determination by rectal palpation. Pulse of pregnancy (fremitus)

2. Pulse of pregnancy (fremitus) By approximately 130 days, the blood flow within the ipsilateral uterine artery has increased to the point at which turbulence is palpable as a buzzing sensation, also referred to as a thrill or fremitus. By approximately 220 days, bilateral fremitus can be felt.

3. WASTAGE OF PREGNANCY

4. When embryo dies before maternal recognition of pregnancy When the embryo dies before day 14 of the estrous cycle then the life span C.L is not prolonged the cow returns to cycle at a normal interval. Goes unnoticed EARLY EMBRYONIC DEATH

5. Genetic defects → defect in the embryo itself there is clearly a lack of cytogenetic evidence Deficient maternal environment → which mediated by inadequate luteal function within the first few days of conception. Sudden changes in diet during the critical early embryonic phase which influence upon the uterine environment (protein trace elements). causes

6. Infection and endocrine imbalance create an adverse environment with in the uterus that prevents the normal development of the embryo. Luteal deficiency may result in embryonic death Stress ( especially heat stress) which create imbalance between oxidant and antioxidants. causes

7. Two possible approaches in the prevention of these early losses are: 1- GnRH injection 2-Progesterone supplementation before day 6-7 These two approaches leads to improvement in pregnancy rate. prevention

8. Late embryos die between 14-42 days. A smaller % of early fetal death occurs after this stage. The lifespan of the CL in all cases is extended this means prolonged interval between successive heats Late embryonic death

9. The same as those for early embryonic death. Genetic abnormality (4.8-26%) Stress Infections causes Ageing of ova- Ageing of cow. Pregnancy diagnosis. cause

10. Abortion is defined as the expulsion of a dead or non-viable fetus at any stage of pregnancy before the time of normal parturition (late 2nd and 3rd trimester). Its frequency is normal for 1-2% of pregnant cows. if the % rises to 5% or more it should be investigated thoroughly. abortion

11. Chlamydiosis Toxoplasmosis Q-fever Listeriosis Leptospirosis Mycoplasmosis Campylobacteriosis Brucellosis Salmonellosis Yersiniosis Trypanosomosis Sarcocystosis anaplasmosis Infectious causes

12. Genetic disorders- habitual abortion may be heritable or cross resulting in abnormal chromosomes Nutritional factors- deficient E & protein in the diet most esp in the late gestation Toxic plants and pharmaceuticals environmental: temperature phytotoxins  including  mycotoxins Locoweed ( Oxytropis or Astragalus sp ) contains an indolizidine alkaloid that can affect the corpus luteum, chorioallantois , and neurons, resulting in abortion or deformities. Broomweed ( Guttierrezia microcephala ) moldy sweet clover. iatrogenic: administration of abortifacient drugs Non infectious causes

13. Extra uterine pregnancies are of two types True extra uterine pregnancy False extra uterine pregnancy In humans, some long existing extra uterine fetuses become quite firm and encapsulated with calcium laid down in the capsule, causing them to be spoken as " Lithopedions " These well encapsulated extra uterine fetuses in animals may occasionally be referred as “ Extra uterine fetal mummies ". Extra uterine pregnancy

14. It is characterized by a fertilized ovum, embryo or fetus that has established nutritive relations with organs or tissues other than the endometrium and has undergone in this location a degree of embryological development. In humans , ovarian and tubal pregnancies may occur, latter being fairly common. True abdominal pregnancies with the placenta attaching to the mesentry and omentum are rare in humans. In ovarian, tubal and abdominal pregnancy, embryonic development proceeds only for a short period and then the fetus succumbs. TRUE EXTRA UTERINE PREGNANCY

15. In human tubal pregnancy, the oviduct ruptures usually accompanied by severe haemorrhage . No authentic case has been observed so far in domestic animals. This difference is apparently related in the manner in which the development of zygote establishes nutritive relationship with the dam. In humans and rodents, the developing zygote erodes the mucosa and buries itself in the maternal tissues while in domestic animals, the villi of the trophoblast attach themselves in the maternal crypts formed in the endometrium. TRUE EXTRA UTERINE PREGNANCY

16. In this condition the fertilized ovum, embryo or fetus develops normal placental relationship with the endometrium and the fetus reaches recognizable size. It then escapes from the uterine cavity either into the abdominal cavity or vagina. Seen occasionally in all domestic animals, and very rarely in mares. Occurs in last 2/3 rd of gestation. Occurs in uterine torsion, fetal emphysema, chronic peritonitis and following dystocia, and administration of oxytocin in bitches. Occur spontaneously or possibly associated with violence in advanced pregnancy. False extra uterine pregnancy

17. In many cases in domestic animals in which a sterile fetus is released in to the abdominal cavity with little or no external symptoms. The fetus dies and with its membranes becomes walled off as a sterile foreign body in the ventral portion of the abdominal cavity and remains there as an inert mass for months. Often extensive adhesion develops between it and other viscera. Site of rupture may be small or invisible scar after the uterus involutes.  Mild digestive disturbance may be present. Occasionally large extra uterine pregnancy may be diagnosed by rectal examination in cow, if the fetus was near term when it escaped from the uterus. False extra uterine pregnancy

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19. In case of cattle the position while standing is also one of the most common cause of torsion

20. Torsion with degree of 45-90 lacks clinical symptoms; if 180° or more definite clinical symptoms are noticed Colicky pain Teeth grinding Restless, Anorexia Lack of rumination Rapid pulse, Tachycardia Treading and tail switching Displacement of dorsal commissure Tucked up udder Vulval edema Slight depression of the lumbo -sacral vertebrae Clinical signs Lateral view Dorsal view

21. Pregnant animals which exhibit the clinical signs must be subjected to both per rectal and per vaginum examinations to arrive at a confirmative diagnosis for Direction of torsion Degree of torsion, and Position of torsion. diagnosis

22. DIRECTION OF UTERINE TORSION   Normal Position of Broad ligaments and vagina. Clockwise ( Right side torsion ). On rectal examination:  The ligament and middle uterine artery (MUA) on the right side  is stretched and pulled vertically downward under the uterus, whereas the  ligament on the left side  is stretched and pulled tightly across the top of the uterine body. Counter clockwise ( Left side torsion ). On rectal examination:   The ligament and MUA on the left side is stretched and pulled vertically downward under the uterus, whereas the  ligament on the right side  is stretched and pulled tightly across the top of the uterine body. 

23. The degree of uterine torsion may be 45°, 90°,180°, 360°, and 540° Per Vaginum examination In Post cervical uterine torsion : Cervix is not palpable with abrupt closing of the vagina. In less than 90°: Hand could be passed to palpate the external Os of the cervix with some resistance. In 90°-180°: One or two fingers can be passed. In more than 360°: Abrupt stenosis. In Pre cervical uterine torsion :  Cervix is palpable and fetus is not palpable. Degree of uterine torsion

24. Position of uterine torsion Post cervical Involvement of vagina Pre cervical Involvement of uterus

25. Manual detorsion per vaginum Manual detorsion per vaginum in combination with external pressure on abdomen Stimulation of vigorous fetal movements Abdominal ballotment Detorsion by simple rotation Schaffer’s method (Modified rolling technique) Intra abdominal manipulation / Flank laparotomy Cesarean section Correction of uterine torsion

26. Assess the side of uterine torsion and cast the animal on the same side as the direction of torsion Cast the animal adopting squeeze method The two hind legs of the cow are fastened together and two front legs are tied together The animals head is held extended The front and hind feet should not be tied together, because this compresses the abdominal cavity and tends to make the gravid uterus rotate with the animal Animal should be rapidly rotated in the same direction of uterine torsion, by strong co-ordinated pulling Technique of simple rollong

27. After the animal has been rapidly rolled 180 degrees, her body must then be either rolled back slowly to the original position or be pushed, usually slowly, over her legs and sternum so that she is once more in lateral recumbency on the same side as the direction of the torsion, ready to be rapidly turned over again. Technique of simple rollong Cow is cast on the same direction and positioned in sternal recumbency . Cow is rapidly rotated on the same direction of torsion. After completion of one rapid rotation.

28. Cast the animal on the same side as the direction of uterine torsion Tie in a manner similar to that described in rolling technique Place the plank (9–12 feet length and 8–12 inches wide) on the animal’s abdomen with the lower end of the plank on the ground  An assistant stands on the plank and the animal is slowly rolled in the same direction as the torsion by pulling on the ropes around the front and hind feet The plank creates pressure first on the upper abdominal wall, then the floor and finally the opposite side of the abdomen resulting in a correction of the uterine torsion that can be determined by examining the genital tract In most cases, the uterine torsion is corrected on the first rolling. Technique of schaffer’s method

29. hgf Technique of schaffer’s method Correction of uterine torsion (right side) in cow by Schaffer's method. Note the placement of plank Correction of uterine torsion (right side) in cow by Schaffer's method. Note assistant standing on the plank

30. Parturition  refers to those events which take place at the end of a normal gestation period, leading to the expulsion of the fetus and the fetal membranes. From the Veterinarians stand point of view One must be familiar with the normal process of parturition in various domestic animals and be able to immediately recognize any deviation and extend artificial interference in order to save the life of the dam and fetus. From the farmers stand point of view Parturition is considered to be a specially important juncture, wherein highest death rate occurs. Furthermore, there may be severe damage or injury to the fetus, and also the dam thus compromising its future reproductive and productive efficiency. parturition

31. The clinical signs observed within few days prior to parturition are categorized as follows Maternal behaviour Changes in pelvis and genital organs Changes in mammary gland Changes in body temperature: Body temperature changes are a signal of impending parturition. In the cow, during the last 7-10 days of pregnancy, a slight decrease in the rectal or vaginal temperature takes place maximum values being attained 2-4 days before commencement of labour . However, this sign for predicting the onset of parturition is limited. Signs of approaching parturition

32. In all species, as parturition approaches, the dam seeks seclusion. Mostly in herds, the expectant dam leaves the herd and prefers quiet surroundings in preparation for the process of parturition. Mares greatly prefer solitude and calm environment, and are more capable than other animals to control or suppress parturition until the night hours. The nesting behaviours are strong in queens, bitches and sows, but is nearly absent in ewes, cows and mares. Maternal behaviour

33. Relaxation of pelvic ligaments and the structures around the perineum is due to the changes in the collagen fibres of the connective tissue, probably caused by an increase in estrogen. In young females, the pubic symphysis undergoes sufficient demineralization or dissolution of connective tissue to allow some separation at the time of parturition. In most cows, presence of very relaxed ligaments indicates that parturition will probably occur in 24-48 h. In mares , sinking of the sacrosciatic ligaments is not so pronounced due to the heavy croup muscles. Changes in pelvis and genital organs

34. hg Changes in pelvis and genital organs Relaxation of pelvic tissues and ligaments May occur up to 10 days prior to calving. Changes are most obvious in the  sacrosciatic ligaments  of pluriparous animals. In cows and buffaloes, results in slight sinking of the gluteal muscles, hollowing of the croup and an elevation of the tail.

35. hjg Changes in pelvis and genital organs Vulval opening increase in size between the dorsal and ventral commissure. In all species, as the labiae enlarge and soften it becomes more mobile and pendulous. In mare, the vulval edema is not so pronounced as in cows. In the bitch, the vulva becomes flaccid, enlarged and edematous.

36. In cow and buffalo The mammary gland becomes distended and swollen that the overlying skin cannot be easily picked up between the fingers and thumb. In heifers, the changes in the udder may commence during mid-gestation, whereas in older pluriparous they may not become evident unit a few weeks before parturition. Changes in mammary gland Heifer Buffalo Cow

37. In mare   Two days before foaling, the colostrum oozes from the teats, called “ waxing”  usually noticed in 95 % of mares 6-48 h before foaling. In bitch, sow and cat The mammary glands become enlarged and edematous and milk may be present in the udder several days before parturition. In the sheep and goat  The development and udder is not so marked. Changes in mammary gland

38. In all species, inappetance , distress and anxiety are observed. The dam may move about in circles. In cows Anorexia and restlessness In heifers Kicking the abdomen Treading Switching of the tail, and Frequent lying down and rising. SIGNS WITHIN FEW HOURS OF PARTURITION

39. In mares No vaginal mucus discharge prior to foaling Sweating in the flank region and frequently behind the elbows. Anorexia 1-2 h before foaling Restless, Frequently lying down and getting up Slight colicky symptoms Switching of the tail The nature of the mucus and volume of mucus produced by the cervical glands increase and they may become so copious that strings are found to be hanging from the vulva, soiling the tail and hocks. SIGNS WITHIN FEW HOURS OF PARTURITION

40. In bitches During the 6-25 h before birth of the first pup, behaviour changes Seeking of seclusion Digging and scratching at the floor Chewing Panting Anorexia Vomiting Shivering. Copious greenish mucoid vaginal discharge before, during and after parturition. SIGNS WITHIN FEW HOURS OF PARTURITION

41. Fetal stress causes stimulation of hypothalamus to release adrenocorticotrophin releasing hormone (ACTRH) which in turn stimulates the anterior pituitary to release adrenocorticotrophin hormone (ACTH). ACTH acts on the adrenal cortex causing release of cortisol. Cortisol acts on the placenta stimulating the enzymes 17 alpha hydroxylase and converts progesterone to 17 alpha hydroxy progesterone which is converted to androstenedione which in turn is converted to oestrogen by the enzyme aromatase. INITIATION OF PARTURITION

42. Oestrogen acts on the cotyledonary caruncular complex to release PGF 2  alpha. PGF 2  alpha in turn cause regression of CL, lower the progesterone level and release of relaxin . Relaxin causes stretching of pelvic ligaments. Increased oestrogen causes stimulation of myometrial contractions which causes the fetus to engage in the cervix thereby stimulating oxytocin which potentiates myometrial contractions. Oestrogen also increases the secretions of the cervix lubricating the birth passage. INITIATION OF PARTURITION

43. Both fetal and maternal mechanisms play roles in initiating parturition. The fetal endocrine system dominates in ruminants ( eg . sheep, goat and cattle) whereas; it plays a minor role in other species ( eg . horse and human). The mechanisms that follow the release of cortisol differ among species depending on the source of progesterone maintaining the pregnancy. In sheep, fetal cortisol induces the placental 17 alpha enzyme to catalyse the conversion of progesterone or pregnenolone to estrogen. The elevated levels of estrogen stimulate secretion of prostaglandin and development of oxytocin receptors. In CL dependent species, cortisol in addition to the synthesis of estrogen causes a release of prostaglandin from the endometrium, which in turn causes regression of the corpora lutea . INITIATION OF PARTURITION

44. INITIATION OF PARTURITION IN COW AND GOAT   (CL dependent Species) INITIATION OF PARTURITION IN SHEEP (CL independent Species)

45. INITIATION OF PARTURITION IN MARE   INITIATION OF PARTURITION IN BITCH  

46. KLC HORMONAL REGULATION OF PARTURITION IN CATTLE

47. First stage: stage of cervical dilation Second stage: stage of expulsion of fetus Third stage: stage of expulsion of fetal membrane STAGES OF PARTURITION

48. Usually last from 3-6 h, but there is often difficulty in determining its beginning. Apparent for longer periods in primiparous than pluriparous animals. During this stage, even though there are no visible external changes, preparation of the birth canal and the fetus for expulsion takes place. This stage marks the onset of parturition and is characterized by Progressive relaxation and then dilation of the cervix, Onset of uterine contraction, and Orientation of the fetus. First stage of parturition

49. In the monotocous species, that part of the birth process in which the foetus is expelled is called the second stage of labour . In polytocous species, the fetal membranes as well as fetuses are delivered during the expulsive phase, the second and third stages being merged. This stage is characterized by Entrance of the foetus into the dilated birth canal Rupture of the allantoic sac Abdominal and uterine contractions, and Expulsion of foetus through the vulva. Second stage of parturition

50. In mare , the chorion separates completely from its uterine attachment during the second stage of parturition. Expulsion of the chorioallantois and attached parts of amnion usually take place in two phases, first being expulsion of the membranes from the non-gravid uterine horn which appears immediately after delivery of the foetus , and remains hanging from the vulva and the gravid horn portion of placenta delivered some time later. Third stage of parturition

51. Following rupture of the umbilical cord, there is a decrease in the amount of blood to the uterus. This causes collapse of the placentomes and separation of the cotyledons from the caruncles due to a decrease in size of the villi and expansion of crypts. Further separation is also brought about by the uterine contractions on which are superimposed bouts of abdominal straining and finally the membranes are expected from the posterior genital tract. In polytocous species,  the dehiscence and expulsion of fetal membranes are interspread with the fetal birth. Third stage of parturition

52. During this stage, rapid and progressive separation of cotyledons from the caruncles occurs so that the entire fetal membranes are eventually expelled form the uterus. The activity of uterine musculature is almost entirely responsible for third stage of labour . This stage consists of dehiscence and expulsion of fetal membranes. In cow , dehiscence is not confined to this stage alone but can occur to a limited extent during first and second stages. common for expulsion of the membrane to be preceded by mild symptoms of colic. Third stage of parturition

53. g Species I stage II Stage III stage Mare 1 - 4 0.2 - 0.5 1.0 Cow & Buffalo 2 - 6 0.5 - 1.0 6 - 12 Ewe 2 - 6 0.5 - 2.0 0.5 - 8.0 Sow 2 - 12 2.5 - 3.0 1.0 - 4.0 Dogs 6 -12 3 - 6 (12) -

54. Parturition may be desirable in animals suffering from a severe illness in that pregnancy as a means of salvaging a live young from her. To save the animal in severe disease condition like traumatic reticulo peritonitis, cardiovascular disease, bronchopneumonia etc. Pre parturient cervico vaginal prolapse in cow Downer cow syndrome Pregnancy toxemia Prolonged gestation Induction of parturition

55. Dexamethasone  (or)  Betamethasone : 25-30 mg  and  Flumethasone :  10-15 mg Parturition is induced within 2-3 days of injection Disadvantages Retained placenta occur up to 90% of treated cows. The onset of milk production is some what slower than normal Delayed uterine involution. PGF 2    (  Natural: 25mg, Synthetic: 500-700 mcg.) can be used successfully from 275 days of gestation onwards. Parturition is induced within 2-3 days of PGF 2  alpha injection. Corticosteroid and prostaglandin combination Advantage -  The interval from the time of induction to calving was reduced. Induction of parturition in cattle

56. Corticosteroids 100 mg at 24 h interval until parturition occur. The average induction time is 4  +  1.6 days. Injections of corticosteroid can be started at 321 days of gestation Disadvantage Repeated steroid treatments create the potential for lowered resistance in the foal. PGF 2  alpha -  Only synthetic prostaglandins are recommended. Dose:   2.2 mg/kg bw . Foaling occurs in approximately 4 h. Natural prostaglandins cause strongest smooth muscle contractions which lead to early placental separation and increased foetal weakness and mortality. Oxytocin The dosage and administration varies with the degree of cervical relaxation. If the cervix is relaxed, 40-60 units of oxytocin are administered as an intravenous bolus. If the cervix is closed, oxytocin can be administered in increments of 10 units at 15-30 minute intervals. Cervical relaxation can be evaluated prior to each additional increment. Birth is usually induced by the time four to five of the 10 unit dose have been given. Combination of prostaglandin and oxytocin Induction of parturition in equine

57. In Sheep Glucocorticoids: 5–10 mg, i /m In Goat   Glucocorticoids: Dose: 5-10mg, i /m PGF 2  alpha Natural: 5-10 mg, i /m Synthetic: 62.5 to 125 µg, i /m The induction time varies between 30-35 h Induction in sheep and goat

58. PGF 2   alpha Natural: 10 mg; Synthetic: 175 µg Pregnant animals should not be treated with PGF 2  alpha  a until day 111 or later to avoid compromising piglet birth, weight and viability. Parturition is induced in majority of the sows from 24-30 h after PG treatment Corticosteroid 75-100 mg ( i /m) on day 101–104 of gestation. Induction of parturition in swine

59. Pureperium  refers to the post-parturient phase including the third stage of labour , during which the reproductive organs gradually return to a structurally and functionally normal non-gravid state. Four main areas of activity Uterine involution. Restoration of endometrium. Return of ovarian cyclical activity, and Elimination of bacterial contamination. pureperium

60. It   is referred to as the reduction in the size of the genital tract. Reduction in size occurs in a decreasing logarithmic scale, the greatest change occurring during the first few days after calving. Uterine contractions continue for several days, although decreasing in regularity, frequency, amplitude and duration. The atrophy of the myofibrils is shown by their reduction in size from 750 to 400 μm on the first day to less than 200 μm over the next few days. Associated with the rapid involution is uterine discharge. In primipara and pluripara , entire uterus is usually palpable per rectum by 8 and 10 days involution

61. Depending on the degree of involvement in placentation, the speed of involution of the non-gravid horn varies. Cervix constricts rapidly postpartum. Within 10-12 h of normal calving, it becomes almost impossible to insert a hand through it into the uterus, and by 96 h it will admit just two fingers. Prostaglandins may have a role in controlling uterine involution, the postpartum rise in the metabolite of PGF 2  alpha may be a reflection of the process of involution involution

62. Age:  Involution is more rapid in primipara than pluripara . Season of year:  Most rapid in spring and summer. Suckling vs. milking Climate:  Heat stress can accelerate and inhibit the speed of involution. Perparturient abnormalities : Dystocia Retained fetal membranes Metabolic diseases: hypocalcemia, ketosis Twin calves Metritis delay involution. Delayed return to cyclical ovarian activity . Factors influencing uterine involution

63. In cows, during the first 7-10 days after calving there is a considerable loss of fluid and tissue debris, inspite of a non-deciduous type of placentation. The presence of such a discharge in cows is normal. It is referred to as the  ‘second cleansing’  or  ‘ secundus ’  by herdsmen. In human gynaecology , the postpartum vaginal discharge is referred to as  lochia . Retained fetal membranes and metritis inhibit healing, whilst ovarian rebound to cyclical activity may have an influence. Restoration of endometrium

64. The lochia are derived from the remains of fetal fluids, blood from the ruptured umbilical vessels and shreds of fetal membranes, but mainly from the sloughed surfaces of the uterine caruncles. Due to the degenerative changes and necrosis of the superficial layers, the slough occurs  Lochial discharge

65. Usually yellowish brown or reddish brown. Volume voided varies greatly from individual to individual. Pluripara can void up to a total of 2000 ml, more usually about 1000 ml, In primipara , it rarely more than 500 ml and in some animals it is occasionally nil, owing to the complete absorption of the lochia. During the first 2-3 days, increased flow of lochia occurs, reduced by 8 days and it virtually disappears by 14-18 days postpartum. At about 9 days it is frequently bloodstained, whilst before it ceases it becomes lighter in colour and almost  ‘lymph-like’ . Normal lochial discharge does not have an unpleasant odour . Lochial discharge

66. days Changes Caruncle within 2 days Evidence of early necrotic changes in the septal mass of the caruncle; the caruncular blood vessels become rapidly constricted and are nearly occluded. A - Septal mass(early evidence of necrosis of    septums ) B - Epithelial lining of endometrium  C - Stratum compactum  D – Myometrium 5 days Rapid necrosis results in a leucocyte-laden necrotic layer on stratum compactum. Some of this necrotic material starts to slough and contributes to the lochia. protrusion of small blood vessels, mainly arteriols from the surface of the caruncle, leads to oozing of blood, causing a red coloration of the lochia. A - Necrotic septal mass. 8 days Complete regenaration of the epithelium occurs in the intercaruncular areas. Caruncular changes in cow

67. days Changes Caruncle Day 10 Most of the necrotic caruncular tissue sloughs and undergoes some degree of liquefaction Day 15 Sloughing is complete, leaving only stubs of blood vessels protruding from the exposed stratum compactum. A - Necrotic septal mass now sloughed. B – Vascular stubs Day 19 Due disappearance of the vessels, the surface becomes smooth. A – Smooth surface of stratum compactum Day 25 Complete re- epithelialisation of the caruncle; which is largely derived from centripetal growth of cells from the surrounding uterine glands Day 40-60 Caruncles become smaller and consist of small protrusions 4-8 mm in dia and 4-6 mm high. Caruncular changes in cow

68. In this period, the ovaries usually have numerous large anovulatory follicles which quickly become atretic . In some instances, it may be incorrectly diagnosed as cysts. In the immediate postpartum period:  Both oestradiol and progesterone are low. During the first few days postpartum:  Anterior pituitary is capable of releasing FSH, so that with the sporadic release of endogenous GnRH there is a gradual and sustained rise in plasma FSH. Return of cyclic activity ( ovarion rebound)

69. After about 7-10 days:  Sufficient to result in the emergence of the first follicular wave: In dairy cattle- occurs at about 4 days. In beef cattle- occurs at 10 days. The ability of the pituitary to release luteinising hormone (LH) is much slower, early release of GnRH causes some rise in LH, it quickly returns to basal levels. the CNS requires prior exposure to progesterone to elicit behavioural signs; a similar phenomenon occurs in ewes at the beginning of the breeding season. Return of cyclic activity

70. Other endocrine organs involved Adrenocorticotrophic hormone (ACTH) and corticosteroid administration suppress the secretion of LH. Stimulation of the teat and milk removal causes a rise in glucocorticoids. Suckling may exert its effect by modifying the tonic release of GnRH and LH by the release of opioid peptides, hence delay cyclicity The role of prolactin is equivocal, there appears to be a reciprocal relationship between the hypothalamic control of LH release and prolactin release Return of cyclic activity

71. Periparturient abnormalities Milk yield Nutrition Breed Parity Season of the year Climate Suckling intensity and milking frequency. Factors affecting ovarian rebound

72. Phagocytosis by migrating leucocytes. Persistence of uterine contractions. Sloughing of caruncular tissue, and Uterine secretions all assist in the physical expulsion of the bacteria. Early return to cyclical activity is probably important since the estrogen dominated uterus is more resistant to infection. Elimination of bacterial contamination

73. Magnitude of bacterial contamination Nature of bacterial flora. Delayed uterine involution. Retained placenta. Calving trauma to the uterus. Return of cyclical ovarian activity. Factors affecing

74. Immediate care C heck for evidence of another fetus Check the entire birth passage to rule out any damage Check for signs of hemorrhage Check the udder for signs of mastitis Check for signs of metabolic disorders Protect the dam against infection by administration of antibiotics, and Administration of oxytocin 60–100 I.U. following calving depending on the size of the cow. Post partum care

75. Mares should foal in a clean, dry, draft-free area that has protection from excessive sun and wind. If the climate permits, a small, clean grass paddock is best During the postpartum period mares need exercise to promote uterine involution and to stimulate appetite and gastrointestinal function. For the first few days after foaling, feeding should be light to moderate, and laxative feeds such as bran mashes are appropriate to reduce the incidence of constipation. Routine care of the mare post partum should include essential preventive medicine procedures. Care of normal postpartum mare

76. Carefully perform routine abdominal ballottement of the doe immediately after parturition for the presence of additional fetuses. Exercise great care to visualize the fetus once the fluid contrast is lost after the chorioallantoic membrane has ruptured. Examine the birth canal for any signs of trauma or hemorrhage. After parturition, assess the doe’s vital signs and muscle tone to detect hypocalcemia, as it may predispose to uterine prolapse. Lochia from normal births may contain  Chlamydia psittaci , Coxiella burnetii ,  or other pathogens that are infectious to humans and other goats. Normal reddish brown lochia must be distinguished from the brownish, watery, malodorous discharge that accompanies postpartum metritis. Postpartum care of doe

77. Onset of spontaneous respiration Acidosis Thermoregulation Care of umbilicus Feeding of colostrum Protect the new born from an excitable or viscious dam. Care and management of newborn

78. In normal calving, spontaneous respiratory movements of the offspring occur within 60 seconds. If there is a delay in calving, sometimes respiratory movements occur before expulsion of the fetus. During the birth process the PO 2  and blood pH are falling and PCO 2  is rising due to start of placental separation, occlusion of the umbilicus, thus restricting gaseous exchange. These changes stimulate chemoreceptors in the carotid sinus for initiation of respiration. Tactile and thermal stimulation are also important for initiation of respiration. Licking and nuzzling of the dam provides some stimulus (In cow and  goat). Onset of respiration

79. Immediately after delivery of the fetus, clear the upper respiratory tract of fluid and attached membranes using fingers. Elevating the rear of the calf will help in escape of copious volume of fluids. Some fluid may also come from the stomach. Brisk rubbing of the chest with straw and towels frequently, provide necessary tactile stimulus for respiration. If spontaneous respiration is not present it may be stimulated by pinching the fetal nose, tickling the nasal mucosa or by splashing cold water. Respiratory stimulants like coramine and adrenaline may be tried. Onset of respiration

80. During normal calving, fetus will usually have a mild metabolic acidosis, corrected within a few hours, and respiratory acidosis, which may last up to 48 hours. Dystocia is likely to cause a severe respiratory and metabolic acidosis and result in adverse effect on both respiratory and cardiac function, and in the case of the calf will reduce vigour , the suck reflex resulting in reduced colostrum intake and impaired passive immunity Metabolic acidosis is primarily due to the production of lactic acid by tissues. Thus it is important that the calf is breathing normally so that it can expire this additional CO 2 . acidosis

81. resence of good muscle tone and a pedal reflex: a well-oxygenated calf with fairly normal acid-base status. Presence of scleral and conjunctival haemorrhages : hypoxia and acidosis - poor prognosis; similar lesions are present extensively at necropsy in calves that die at birth  Simple method of assessing the degree of acidosis, based on the time to the calf assuming sternal recumbency Assessment of acidosis Sl.No Feature Time taken to assume sternal recumbency (in minutes) 1 Normal calving 4.0 ± 2.2 2 Traction 9.0 ±3.3 3 High predictive value for death of the calf >15

82. A calf requiring resuscitation is likely to be suffering from both a metabolic (low plasma bicarbonate concentration) and a respiratory (high PCO 2 ) acidosis. The PCO 2  will be reduced with improved alveolar gas exchange and tissue perfusion. Assess the degree of metabolic acidosis using blood gas analysis., under field conditions this is seldom possible. A newborn calf with the history and clinical signs suggestive of acidosis, sodium bicarbonate at a dose rate of 1-2 mmol /kg as a bolus intravenous injection of 50-100 ml (35 gm in 400 ml of lukewarm water) can be used quite safely  Treatment of acidosis

83. Thermoregulation is controlled in two ways: By increased metabolic rate for which adequate glycogen reserve is required. Reduce heat loss: The new born has little subcutaneous fat and hence insulation is poor. Ensure that there is adequate food and arrange for birth to occur in at least a thermally controlled environment. Reduced heat loss by ensuring that the coat is adequately and quickly dried. The neonates should be placed in a warm environment until they can be returned to the dam. thermoregulation

84. The haemostatic clamp is removed from the umbilical cord, which is checked for haemorrhage . Should bleeding occur the cord may be ligated with a suitable suture. It is important not to cut the cord too close to the abdomen, first to allow the placement of a further ligature if needed in case of bleeding and for spontaneous vasoconstrictions of the cord after birth to allow for the blood included in the cord to be reused by the neonate thus reducing the amount of blood loss. The umbilical cord should also be disinfected with mild antiseptic. Care of umbilicus

85. Colustrum with a high immunoglobulin (IgG) concentration is thick and sticky with either a yellow or gray tinged appearnance . The new born should recieve colostrum from the dam. If new born is delivered by assistance or through c-section , then it has to be assisted. Colostrum should be made available to the new born during the first 24 h of delivery, after which time its absortion is greatly reduced. Feeding of colostrum to the young one provides antibodies. Colostrum can be stored in clean labeled containers in a refrigerated freezer (-5 °C) for approximately 18 months without degradation of the IgG. Frozen colostrum can be thawed in warm water or in a microwave on the defrost cycle. Feeding of colustrum

86. Eutocia  refers to safe, easy, natural, or physiological parturition. Dystocia   (Greek terminology) refers to difficulty in birth. When the first or usually the second stages of parturition gets markedly extended, it becomes difficult or impossible for the dam to deliver without artificial interference. dystocia

87. It   may be divided into the following categories: Hereditary Nutritional and management Infectious, and Traumatic Many cases of dystocia may have two or more basic causes. Basic causes of dystocia

88. Persistence of the median wall of the mullerian duct with a large band inside or caudal to the external os of the cervix. Twining in cattle commonly result in dystocia. The hidden and recessive genes produce a variety of pathological conditions affecting the foetus or foetal membranes. Dropsy of foetus or fetal membrane Acroteriasis congenitia , hydrocephalus. Foetal anasarca Autosomal recessive gene causing prolonged gestation. Muscle contracture monsters are usually produced by general functional ankylosis with an abnormal development of muscle and tendons causing an immobility and extreme rigidity of affected limbs. Hereditary causes

89. Improper nutrition of the growing heifers was the most important factor in retarding body and pelvic growth. Dystocia may arise due to Small pelvis Under developed juvenile genital tract, and  Lack of strength to expel the foetus . Breeding a poorly grown, underfed female that may be old enough to breed, but the body growth has been greatly retarded due to poor nutrition, parasitisms or diseases. It has been suggested that dairy heifers may be bred by size or weight rather than by age. Nutritional and managemental causes

90. High feeding levels may favour dystocia By excessive deposition of fat in the pelvic region predisposing to difficult parturition, especially in heifer. Favour the development of a larger fetus (especially high feeding during the last third of pregnancy). The balance between fetal size and pelvic or genital tract diameter is thus upset and dystocia is favoured . Malformation of the pelvis such as pelvic rickets due to improper mineral balance or lack of vitamin-D is seen in humans. Nutritional and managemental causes

91. Close confinement of pregnant animals without exercise, are prone to Torsion of uterus, and Uterine inertia. During parturition all animals should be watched closely, if possible, so that prompt aid may be given if parturition is not normal. This aid may prevent Secondary uterine inertia Death of the foetus Rupture of the uterine or birth canal Septic metritis Retained placenta, and Obturator nerve paralysis. Nutritional and managemental causes

92. Any infection or disease affecting the pregnant uterus and its contents may cause dystocia. In infection of th uterus, the uterine wall may lose its tone or ability to contract a condition resulting in complete dilation of the cervix and uterine inertia. To help control infections that predispose to uterine disease and foetal death, both the sire and dam should be free of infection at the time of service. All known infectious diseases such as brucellosis, leptospirosis, vibriosis , salmonellosis, viral and other septic diseases should be controlled according to our best knowledge at the present time. Infectious causes

93. The traumatic causes for dystocia are not common. Ventral hernia and rupture of the prepubic tendon late in gestation may occur from traumatic causes. These injuries render the abdominal wall incapable of strong contractions resulting in inability to force the foetus through the birth canal. A fracture of the pelvis with secondary deformity and exostosis is seen most commonly in small animal, which may result in a stenosis of the birth passage resulting in severe dystocia. The basic causes of dystocia are multiple, but by properly applying our knowledge, its incidence may be kept at a minimum. Traumatic causes

94. Presentation [P 1 ] The relation of the spinal axis of the fetus to that of the dam The portion of the fetus that is approaching of entering the pelvic cavity. Presentations are either longitudinal or transverse Anterior/ Posterior  longitudinal Dorsal/ Ventral transverse Position   [P 2 ] The position includes the dorsum of the fetus in longitudinal presentation, or the head in transverse presentation, to the quadrants of the maternal pelvis. The quadrants are the sacrum, the right ilium, the left ilium and the pubis terminology

95. Posture   [P 3 ] The posture signifies the relation of the extremities of the fetus or head, neck and limbs to the body of the fetus The normal presentation in uniparous animals is the anterior longitudinal presentation, dorso -sacral position with the head resting on the metacarpal bones and knees of the extended fore legs. Birth can also take place without assistance, if the fetus is in the posterior longitudinal presentation, dorso - sacral position. terminology

96. In monotoccus animals,   normal delivery will occur only if the fetus is presented in anterior or posterior longitudinal presentation (P 1 ), dorso -sacral position (P 2 ) and with the head, neck and limbs extended posture (P 3 ). In polytoccus animals,   due to small and flexible limbs, normal delivery can occur even though the limbs are retained alongside of or beneath the body. Normal fetus

97. Mutation: Repulsion Rotation Version, and Adjustment or extension of the extremities carried out on the fetus thereby restoring it to a normal presentation, position and posture. Correction of dystocia

98. Repulsion  refers to the act of pushing the fetus from the vaginal passage into the uterine cavity, in order to create space and thereby rectify the defects of presentation, position and posture. Points of repulsion: In anterior presentation:  Arm or instrument is placed between the shoulder and chest or across the chest beneath the neck of the fetus. In posterior presentation:  Arm or instrument is placed in the perineal region over the ischial arch. repulsion

99. Rotation  refers to the act of turning the fetus on its long axis to restore the fetus in to a dorso -sacral position. More often required in mares than in cows. rotation version Version  refers to the act of rotation of the fetus on its transverse axis into an anterior or posterior presentation Version is usually limited to 90 ° Transverse presentation is corrected to either anterior or posterior longitudinal presentation by repulsion of either the cranial or caudal portion of the fetus, and exerting traction to the other end.

100. Extension and adjustment of extremities  refers to the process of correction of abnormal postures usually due to flexion of one or more of the extremities leading to dystocia. Repulsion of the proximal portion of the extremity such as the shoulder or chest in anterior presentation and on the buttocks, stifle, or tarsus. Lateral rotation of the middle portion of the extremity, carpus, tarsus, or neck, and Traction on the distal portion of the extremity such as the pastern, lower jaw or, until these distal structures can be reached, the structures between the body and the distal portions of the extremity. Extension and adjustment of extermities

101. Forced extraction refers to the delivery of the fetus which is in normal presentation, position and posture through the birth canal of the dam with the aid of external force or traction. Indicatons : Uterine inertia Following epidural anesthesia and mutation operation. Fetus is relatively too large to be expelled through the birth canal without assistance. In primipara with a small birth canal. In cases where birth canal compressed by tumors or fat or other pathological conditions. Forced extraction

102. In anterior presentation Applied to pasterns or above the knee or elbow. Around the lower jaw. Around the neck in dead fetus. Loop around the poll, under the ears and through the mouth. Inner canthus of the orbit. In posterior presentation Applied to pasterns or above the hocks. In dead fetus, on top of the fetal croup and turned ventrally to engage the posterior border of the ischium or sacrosciatic ligament. Points of traciton

103. Fetotomy   refers to those operations performed on the fetus for the purpose of reducing its size by either its division or removal of certain of its parts. In most cases these operations are performed within the uterus of the dam. Types: Subcutaneous or intra fetal method Percutaneous or extra fetal method. fetotomy

104. Complete fetotomy   in anterior presentation involves the following Amputation of the head Percutaneous amputation of the forelimb Transverse division of the fetal trunk Longitudinal division of hind quarters fetotomy

105. Complete fetotomy in posterior presentation involves the following Percutaneous amputation of posterior limb Transverse division of fetal trunk (Lumbar area) Transverse division of fetal trunk (Scapular area) Diagonal - Longitudinal division of the fore part Percutaneous amputation of both fore limbs fetotomy

106. Amputation of head

107. Precutaneous Amputation of forelimb

108. Deviations of head and neck are common types of abnormal posture in anterior presentation causing dystocia in all species. In swine, because the neck is so short this type of dystocia is very rare. Lateral Deviation Of The Head   Wry – Neck Downward Deviation Of The Head Deviations Of the forelimbs Carpal flexion Shoulder flexion Dystocia in anterior presentation

109. Hock flexion Hip flexion ( breech presentation ) Dystocia in posterior presentation

110. Includes relative and absolute fetal over size, small maternal pelvis and narrow birth canal. This can be regarded as one syndrome in which both fetal and maternal factors interplay. This is type of dystocia is caused by a disparity in size between the fetus and maternal pelvis when the cervix is fully dilated and vagina and vulva are relaxed. Feto pelvic disproportion

111. In dairy cattle, most often cause dystocia. Common conditions include: Schistosoma reflexus , Ankylosed calves including Perosomus elumbis Double monsters Dropsical fetuses, including anasarcous and hydrocephalic calves, and anchondroplastic monsters. In sheep, same occur but to a lesser extent. In mares, with the notable exception of wryneck, monstrosities are uncommon. Dystocia due to monsters

112. In the cow, goat and ewe: Occasional In other domestic animal: Rare In mature and old cow: More frequently seen than in heifers. In cow, goat and ewe, the cervix is more muscular, fibrous and tightly closed during pregnancy than in majority of domestic animal and may cause a severe dystocia if not properly relaxed or dilated. Incomplete cervical dilataton

113. The expulsive force of labour comprises the contractions of the uterine and abdominal muscles. Because the abdominal muscles do not come into play until the uterine muscles has lifted the conceptus into the pelvic inlet it is logical to consider first the expulsive deficiencies that may occur in the myometrium. These are known as Primary uterine inertia, and Secondary uterine inertia. Uterine inertia

114. Primary uterine inertia implies an original deficiency in the contractile potential of the myometrium. It is less common than secondary uterine inertia and is seen most often in the dog and sow, occasionally in cow but rarely in other species. Incidence in cattle is more as age advance. Primary uterine inertia

115. his usually follows a prolonged dystocia and is characterized by exhaustion of the uterineuscles . It is essentially a result of, rather than a cause of dystocia. This condition is seen in all species of animals and is more common in large animals. Secondary uterine inertia is frequently followed by retention of fetal membranes and retarded uterine involution. Secondary uterine inertia

116. Correcting head back dysotcia

117. Dystocia with limb back (fore-leg)

118. Dystocia With a Posterior Leg Retained

119. Breach Dystocia

120. Placing OB Chains

121. 124 Classification of placenta Species Gross shape of placenta Microscopic structure Loss of maternal tissue at birth Mare and Sow Diffuse Epitheliochorial Non deciduate Ruminant Cotyledonary Syndesmochorial Non deciduate Dog and cat Zonary Endotheliochorial Deciduate Human and Monkey Discoidal Hemochorial Deciduate

122. 125 Cell Layers Separating Fetal & Maternal Blood

123. UTERINE INERTIA BY UMOH EMMANUEL

124. DEFINITION abnormal relaxation of the uterus during labor, causing a lack of obstetric progress, or after childbirth, causing uterine hemorrhage. Can be associated with dystocia

125. CLASSIFICATION HYPOTONIC INERTIA : a. Primary Uterine inertia b. Secondary inertia HYPERTONIC INERTIA: a. Colicky Uterus b. Hyperactive lower uterine segment

126. PRIMARY UTERINE INERTIA Is characterized by inefficient contractions from the very beginning of labor, the contractions are usually weak and short, while the pauses between them are long. Frequent, but ineffective contractions may also occur. Usually occurs in general asthenia conditions, endocrine disorders, infantilism, malformation of the genitalia( uterus bicornuate and unicornus ), myoma of the uterus and obesity.

127. Aetiology Unknown but the following factors may be incriminated: GENERAL FACTORS :Primigravida particularly elderly. Anaemia and asthenia. Nervous and emotional as anxiety and fear. Hormonal due to deficient prostaglandins or oxytocin as in induced labour. Improper use of analgesics.

128. Contd. LOCAL FACTORS :Overdistension of the uterus in multiple pregnancy and polyhydroamnions Developmental anomalies of the uterus e.g. hypoplasia . Myomas of the uterus interfering mechanically with contractions. Malpresentations , malpositions and cephalopelvic disproportion. The presenting part is not fitting in the lower uterine segment leading to absence of reflex uterine contractions. Full bladder and rectum.

129. Uterine inertia often results in premature discharge of the amniotic fluid in the absence amnion which stimulates the nerve elements of the uterine cervix and intensifies the uterine contraction. Primary inertia may last to the second stage of labor to become responsible for ineffective abdominal contractions, labor thus becomes markedly prolonged. This can lead to complications such as: fetal asphyxia, considerable bleeding in the placental and early puerperal period.

130. CLINICAL PICTURE OF HYPOTNIC INERTIA Labour is prolonged. Uterine contractions are infrequent, weak and of short duration. Slow cervical dilatation. Membranes are usually intact. The foetus and mother are usually not affected apart from maternal anxiety due to prolonged labour . More susceptibility for retained placenta and postpartum haemorrhage due to persistent inertia. TOCOGRAPHY : shows infrequent waves of contractions with low amplitude.

131. MANAGEMENT Usually difficult to manage, but one principle is to find the cause and treat the cause if possible. Schemes used: SCHEME 1 (KURDINOVSKIY AND SHTEIN) Castor oil, 50-60g per os ; a cleansing enema in 2hrs, Quinine 0.2g six times at 30min interval after enema. 15 mins later, the 3 rd ,4 th , 5 th and 6 th dose of quinine follows pituitrin injections( subcutaneously 0.25ml 4 times). If the membranes are intact, 40,000-50,000units of folliculin or sinestrol intramuscularly may be given at the beginning of labor. Folluculin and sinestrol increases sensitivity of the uterus to quinine, pituitrine and other uterine stimulants. Castor oil is given in an hour after the administration of folliculin , then given are cleansing enema, quinine and pituitrin .

132. SCHEME TWO( A.P NIKOLAEV) Castor oil , 60g per os , then (in an hr ), quinine, five 0.2g doses at 30minutes interval. After the 5 th admission of quinine, a cleansing enema is given followed by an intravenous injection of 50ml of 40% glucose and 10ml of 10% Calcium Chloride. Solution of vitamin B (160mg) should be given simultaneously ( i.m )

133. SCHEME 3 (V.N KHEMLEVSKY) A mixture of 50g of glucose, 2g of Calcium Chloride, 0.5g of ascorbic acid, 0.3g of vitamin B1, 10 drops of dilute hydrochloric acid, and 150ml of water are given per os in a single dose. The mixture can be given in 3hrs again.

134. Cont. Oxytocin and Prostoglandin have been recently used as uterine stimulants. Oxytocin is given as i.v with glucose solution (5-10units of Oxytocin in 5% of 500ml glucose by infusion)…speed of drops : 10drops per minute, increase drops after some hours depending on the condition of the patient. Proserine plus Atropine hydrochloride can be given as 0.003g and 0.002g respectively in powder from an hour interval( 4-5times a day) Prostaglandin is contraindicated in traumas and hypertensive patients.

135. SECONDARY UTERINE INERTIA A condition that develops during the second (expulsive) stage of labor or at the end of dilation stage following normal or satisfactory uterine contractions.

136. etiology Often develops in prolonged labor due to general fatigue of the Parturient and extraction of the contractile power of the uterus. Occurs in: Contracted pelvis large sized fetus Malpresentation, rigid Os , Cicatrical narrowing of the vagina delayed rupture of membranes

137. Pathphysiology It often occurs after discharge of the amniotic fluid and its therefore often attended with intrauterine infection and fetal asphyxia.

138. Management Depends on the cause , if its due to delayed rupture of the membranes, AMNIOTOMY is indicated . When the cervix is fully dilated and the fetal head is engaged, 1ml of pitutrin or 0.25ml of Oxytocin may be given simultaneously which will rapidly stimulate uterine contractions.

139. GENERAL MANAGEMNET OF HYPOTONIC INERTIA General measures:Examination to detect disproportion, malpresentation or malposition and manage according to the case. Proper management of the first stage (see normal labour). Prophylactic antibiotics in prolonged labour particularly if the membranes are ruptured.

140. CONTD. Amniotomy:Providing that; vaginal delivery is amenable, the cervix is more than 3 cm dilatation and the presenting part occupying well the lower uterine segment. Artificial rupture of membranes augments the uterine contractions by: release of prostaglandins. reflex stimulation of uterine contractions when the presenting part is brought closer to the lower uterine segment.

141. CONTD. Oxytocin : Providing that there is no contraindication for it, 5 units of oxytocin ( syntocinon ) in 500 c.c glucose 5% is given by IV infusion starting with 10 drops per minute and increasing gradually to get a uterine contraction rate of 3 per 10 minutes. Operative delivery: Vaginal delivery: by forceps, vacuum or breech extraction according to the presenting part and its level providing that, cervix is fully dilated. vaginal delivery is amenable. Caesarean section is indicated in: failure of the previous methods. contraindications to oxytocin infusion including disproportion. foetal distress before full cervical dilatation.

142. HYPERTONIC UTERINE INERTIA (Uncoordinated Uterine Action) Types Colicky uterus: incoordination of the different parts of the uterus in contractions. Hyperactive lower uterine segment: so the dominance of the upper segment is lost.

143. CLINICAL PICTURE The condition is more common in primigravidae and characterised by: Labour is prolonged. Uterine contractions are irregular and more painful. The pain is felt before and throughout the contractions with marked low backache often in occipito -posterior position. High resting intrauterine pressure in between uterine contractions detected by tocography (normal value is 5-10 mmHg). Slow cervical dilatation . Premature rupture of membranes. Foetal and maternal distress.

144. Management General measures: as hypotonic inertia. Medical measures: Analgesic and antispasmodic as pethidine. Epidural analgesia may be of good benefit. Caesarean section is indicated in: Failure of the previous methods. Disproportion. Foetal distress before full cervical dilatation.

145. Lateral deviation of head The head may be displaced to either sides and this is one of the most common types of dystocia in cow. In cattle, the head most commonly is deviated to the left side of the fetus and lies against the thoracic wall. When this condition occurs, only the foetal limbs will be presented at the vulva and per vaginal palpation may reveal absence of the head.

146. Correction Apply snares at the presented limbs and apply retropulsion at the base of the neck. Locate the head and the malposture is corrected by grasping the orbital grooves with the thumb and middle finger (forceps grip) and drawing the head into the maternal pelvis. A rope snare placed behind the incisor teeth may be useful in difficult cases. Traction to redirect the head can be applied with the snare by the operator or by an assistant while with the other hand the operator guides the head and protects the uterine wall from the incisor teeth by covering the fetal mouth

147. Downward displacement of head: