PROLAPSES - cdn.ymaws.com · get up. But it is not necessarily the prolapse that killed her. 5. A warning! After a difficult prolapse (some can take up to an hour or so of kneeling

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CATHY THOMPSON BVSc. | PROLAPSES

PROLAPSES

UTERINE PROLAPSES

Two common presentations:

Cow with Milk Fever - the muscles of the uterus have no tone due to lack of calcium and don’t contract

when the cow calves.

Heifers or cows with big calves - the muscles of the uterus are exhausted from pushing out a big calf and

don’t contract. These cases used to be common in first calving heifers in calf to large bulls (anything but

Jersey). Much less common now that most farmers use Jersey bulls over heifers.

TIPS ON APPROACHING A PROLAPSE CASE

• If cow is down with milk fever sit her up with a halter and give calcium under the skin (or orally if the

cow is swallowing well). Halter is then to stop the cow escaping if there is a good calcium response.

This cow had milk fever.

This “flat-out” position makes it harder to replace even this small, fresh prolapse. It is also more dangerous for a cow (or heifer) as lying flat out she can bloat and may regurgitate while everyone is concentrating on the prolapse.

It also deprives the farmer of a warm seat!

• Put the cow in the “prolapse position”. This looks strange but makes replacement a lot easier as the

cow’s pelvis tilts and you are pushing down. A cow in flat-out or normal sitting position means you will

be pushing uphill when replacing the uterus.

If the cow is lying flat-out sit her up with a halter. Pull her top hind leg behind her as she sits up so that

she is sitting on her stifle. Push her over onto this leg when she is in the sitting up position - just enough

to take the weight off the other hind leg. Then grab the other hind leg and pull it out behind her.

Prolapse position, placenta gone.

Prolapse position, some placenta still attached.

332 PRACTICAL GUIDE FOR CATTLE VETERINARIANS

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• Preferably have the cow facing downhill (gravity assist).

• Quick check of rest of cow. Does she have difficulty breathing or grass/ rumen contents in her nostrils?

Large calf /possible paralysis? Worse prognosis if either of these present.

Rumen contents in nostrils and on the ground.

Any sign of regurgitation worsens the prognosis but a few of these cows will survive without getting

inhalation pneumonia. Antibiotics needed no matter how undamaged and fresh the prolapse seems.

• Give epidural – easier when the cow is sitting in prolapse position. 5ml local anaesthetic 18-gauge x

1inch needle (or 1 ½ inch needle for fat cows and beefies).

• Clean uterus – I think clean water is fine. Attempt to remove placenta if present – see below.

• Peeling off the placenta if still present (see below) is a good learning opportunity for farmers and

helpers. If the placenta is still attached and not “peeling off” nicely cut off the bulk of it with scissors and

proceed as below.

• Use lots of lube

• Put the whole uterus in your arms or on plastic sheet/towel etc. Tuck in “buttons” as you push the

uterus back in. Sometimes it’s helpful to get someone to hold the vulval lips open.

• I always wear my calving gown and leggings which keeps me relatively dry but is also a clean surface

for the uterus to rest on.

• Occasionally the bladder will be very full and prevent replacement. This is usually noticeable as a solid

lump when about 2/3 of the uterus is back in. In this case you can put a 14- gauge needle in to empty

some urine.

Large animal memories: Definition of an optimist

A large herd with a history of 20% empties every season told me they had bought special leg bands

to put on the empties. By the end we had not only used all the new leg bands (enough for 10% of

the herd) but had used all their old leg bands and most of my spray marker as well.

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Left: Using lube.

Above: Almost!

Left: Stage 1 done

• Once the uterus is back in the cow (stage one done) you must “spread it out” so that it is completely

everted otherwise there is a good chance of the uterus prolapsing again. This is “stage 2”.

A lube or drenching bottle may be needed. Inserting a large bottle (1-2 litre size) into the vulva at this stage

will often look horrible to farmers but I just remind them that a 20-40kg calf recently exited the same

orifice!

• Use 5-6ml oxytocin intramuscularly and other treatments as required.

• Calcium important in all cases. Even heifers should get some under the skin or orally as it helps with

muscle contraction (not i/v in heifers as they don’t have milk fever). In milk fever cases give calcium

i/v now.


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• Consider antibiotics. Spray the cow with marker spray if withholding time involved. Think positive!

• Anti-inflammatories are always useful whether for the associated paralysis if a large calf was the

problem or general pain and squashed muscles with a milk fever cow.

• No suturing is needed. If anyone questions this explain that if the uterus is correctly replaced and

the cause treated it will not come out again. If it does re-prolapse it is better for it to be visible (and

retreated) than stuck in the vagina going necrotic due to interference in the blood supply.

• A vaginal or cervical prolapse does require suturing. The difference here can cause farmer confusion,

especially for ex-sheep farmers. Sheep often have vaginal prolapses (“bearings”) but uterine prolapses are

very uncommon. Vice-versa for cattle.

• If the cow gets up straight away that’s a really good sign. If the cow won’t or can’t get up it is a good idea

to leave her for half an hour or so to give the epidural a chance to wear off and the anti-inflammatories

and other treatment to start working.

STANDING PROLAPSE CASES

Some good signs here:

1. The placenta had already detached.

2. The cow is standing.

3. The cow is in a yard

4. No obvious damage or excessive bleeding.

If this cow was standing in the middle of a

paddock far from any shed or yards the fact she

is standing would be a bad sign as restraint will

be difficult.

In that case it is advisable to walk the cow slowly

to the yards or get her somewhere she can be

restrained for treatment eg. behind a swinging gate

or against a solid fence hemmed in by bike, ute etc.

There are very few farms with this option as most

fences are electric and most gates are tape.

Attempting to restrain the cow or let her run to the

yards may result in damage to the uterus and/or

rupture of the middle uterine artery

– see examples below.

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• Replacing a prolapse with the cow standing isn’t as hard as a flat out or sitting down cow but sometimes

it is necessary to cast the cow with ropes so the “prolapse position” can be used.

FURTHER PROLAPSE COMMENTS

1. When replacing a prolapse it is easy to damage the uterus. Full thickness tears should be sutured but

partial thickness tears are often better left alone. Once the prolapse is replaced the oxytocin should

contract the uterus and make these less important. Of course, this is a reason to use antibiotics.

2. Some vets have recommended using oxytocin intramuscularly or injected into the muscle of the uterus

in very large prolapses to make them smaller and assist with replacement. I tried this once (desperate

situation) and it didn’t improve things. I imagine oxytocin would make the uterus hard and contracted

and therefore harder to manipulate.

3. Sometimes caruncles are torn off the uterus during replacement. If bleeding excessively the damaged

blood vessels can be ligated. The caruncles in a normal uterus almost disappear a few weeks after

calving and reform at the next pregnancy, so don’t panic if a few end up on the ground!

4. It’s hard to predict outcomes in prolapses.

I remember a beef cow a few years ago that had prolapsed - she was flat-out, thin and the uterus

was a bit damaged. I was tempted to suggest euthanasia but gave a poor prognosis and fixed her

up as the farmer was keen. The following year I was back to pregnancy test the group and the

farmer said: “this will be interesting - she’s the one that had the prolapse last year”. To my

amazement she was in calf again (couple of big Hereford calf feet kicked me when I did the

manual PD) and looking great.

There are other cows which look good at the time of treatment but die soon after.

This is a relatively clean, smallish prolapse which was replaced easily. The cow never got up and died of inhalation pneumonia. Treatment for milk fever was too late in this case.

However, in a cow with a prolapse, it is the obvious thing for the farmer to blame if the cow doesn’t get up. But it is not necessarily the prolapse that killed her.

5. A warning! After a difficult prolapse (some can take up to an hour or so of kneeling and hard work) you

probably won’t be able to walk downstairs without pain for about a week! It’s hard exercise for the

your quadriceps!


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PROLAPSE CASE EXAMPLES

Eric’s cow

I once had to tranquillise a standing cow with a uterine prolapse. She was out in the back paddock

and quite lively. The farmer and I managed to get her between a gate and a boxthorn hedge. I gave

her xylazine in the tail vein. She went down and I treated her but she was twitching rhythmically the

whole time. We found out after she got up that she had been sitting on an electric wire hidden in the

long grass!

Phil’s cow

I went to a prolapse one evening when the cow was a very stroppy Friesian a long way from the

shed. There were at least three guys there as well as me but we were unable to get close enough to

her to deal with the prolapse. Despite my warnings the “boys” got all keen and chased the cow until

she slowed up and eventually went down. In this situation you can usually see the protruding uterus

getting longer and longer. They all pounced on her and I raced over to get the prolapse back in.

Replacement took less than 5 minutes but I wasn’t surprised when the helper sitting with the cow’s

head suddenly said – “she’s dead”. This is likely a case of the uterine arteries rupturing and the cow

bleeding to death internally.

Jim’s cow

I remember a “routine” prolapse in a down cow with milk fever. She had not been up since calving

and had an undamaged uterus (no ruptured arteries) but she died as I drove out the gate! I found

this out much later from the disappointed farmer. I suspect she may have had an embolism from a

disturbed blood clot.

Trev’s cow

A standing case I remember was brought up the front of the herringbone shed. When I was half

way through the replacement the cow suddenly jumped into the pit. The uterus fell out again! She

then dragged herself up the steps and took off into the yard. She was bought back in and I replaced

the uterus. After treatment she walked out of the yard and sat down about 20 metres away in the

paddock. She was found dead in the same position the next morning. Another case of internal

bleeding I suspect. I now put a halter on the cow to prevent escape.

A uterine prolapse will not recur the next year unless the same risk factors occur again (milk fever or a large

calf). This is unlike a vaginal or cervical prolapse which nearly always recur the following season.

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Heifer down with paralysis after a large calf. She had a prolapse also. Placenta still attached.

Placenta tearing rather than peeling off in heifer shown on left. This depressed, paralysed heifer never got up but the prolapse was only partly to blame.

Cow with milk fever and very large, solid, heavy prolapse. I suspect there were guts inside the prolapse.

I replaced the uterus with great difficulty (see desperate measures below!) and the cow died the next day. Possibly due to secondary damage to the gut.

When guts are inside the uterus I give a very poor prognosis. Heroic colleagues have told me they have

incised the uterus, identified the guts, replaced them in the abdomen and sutured the uterus before

replacing it. Outcomes?? No idea.

Amputation of the uterus is a last resort but I have never performed this procedure.

Kevin’s cow

A colleague was called to a cow down with a uterine prolapse. The prolapse was so bad that

Barbara’s only option was to amputate the uterus. Kevin watched the whole performance carefully

and once the procedure was finished and the discarded uterus was on the ground beside the cow

he asked “what are her chances of getting in calf next year?”.


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DESPERATE MEASURES

1. If the uterus won’t go back in – assuming you have tried the prolapse position and the gravity assist

and still no success it’s time for desperate measures! Hip lifters (which most farmers have) can be used

to briefly lift the cow’s backside up to give lots of gravity assistance.

2. If uterus very hard and inflexible try a tocolytic such as “Duphaspasmin” or “Planipart”.

This type of product should relax the smooth muscle of the uterus and help with replacement.

Don’t use routinely as the uterus won’t usually respond to oxytocin for some time afterwards and

oxytocin causing muscle contraction is very important for retaining the prolapse.

UNUSUAL CASES

Hayden’s cow

I had a situation where a standing cow kept re-prolapsing her uterus over several days. A colleague had

been dealing with the case and had replaced it at least twice only for it to come out again each time.

So, it was my turn! I replaced it relatively easily (stage 1 ok) but could feel that part of the uterus was

very hard and not everting when inside the cow (stage 2 not working). Presumably the same thing had

happened before. The cow had had lots of oxytocin before this.

I decided to try something counter- intuitive - “Planipart” tocolytic. After replacing the uterus

I administered Planipart. After a while I was able to evert the uterus properly and it never came

out again.

Bob’s heifer

An “internal uterine prolapse” is the only way I can describe this situation. This heifer was standing

and straining around calving time. I expected a calving but on examination found the heifer had

already calved. However, the uterus was inverted inside the vagina. There was nothing visible outside

the vulva. I couldn’t evert it (too contracted and hard) and was worried about damaging the tissues

so tried the above trick with “Planipart” and was able to replace it. Heifer fine.

I couldn’t walk without pain for a week after this one! Took over an hour.

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VAGINAL AND CERVICAL PROLAPSES

• Generally occur before calving. Uncommon compared to occurrence in sheep. Called “bearing out”

in sheep.

Cervical prolapse in a dairy cow. Surprisingly I replaced this fairly easily!

Very fresh cervical prolapse in a dairy cow.

• Often fat cows. Photos above are cervical prolapses. Vaginal prolapses are more common. They are

smooth and red, not lumpy as the cervical ones are.

• Will most likely recur the following season so culling at the end of the season should be recommended.

Same with sheep.

• Epidural needed. Often an 18-gauge x 1½ needle needed for fat cows. Generally, a 1-inch needle is ok

for an epidural. This will anaesthetise the area for suturing and stop straining.

• NSAIDS should be used to try and minimise straining after replacement.

• Wash the prolapse with clean water. A hose is sometimes useful.

• If bladder involved you can sometimes release urine by lifting the prolapse upwards. This makes

replacement easier and the cow has one less excuse to strain when the epidural wears off.

• Use lube to replace. Often easier than it looks- if the prolapse is relatively fresh.

THE SUTURE I USE IS A “SHOELACE” ARRANGEMENT

• 3-4 loops each side of vulva.

• Use doubled skin suture material, large chromic catgut or umbilical tape placed vertically deep into

the tissue where the hair starts at the side of the vulva. Simple interrupted sutures used. Positioning is

important - vulval lips are not strong enough.

• The loops need to be fairly tight such that you need forceps to thread the string through.

• I usually get the farmer to hold a haemostat or scissors under the first suture throw as I tie the knot so

the loop is not too big or too small

• Thread string in shoelace fashion through the loops starting at the top.

• Tighten the string with very small gap at the bottom to allow urine to escape.

• Tie a knot with lots of throws (synthetic string tends to undo).

• Spray area with “purple spray”.

• Antibiotics can be used if necessary but remember the calf inside will have a meat withholding time as

well as the cow.


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This is the cow above on the left after prolapsed cervix was replaced.

4 suture loops placed – 2 each side. I normally use 6 (3 each side), occasionally 8.

Large catgut sutures (yellow arrows) placed away from the vulval lips.

• As most cases occur before calving the cow must be watched closely for signs of calving and the string

removed.

• It is possible for the owner to remove the string and leave the loops in place if it’s expected the cow may

calve. The string can be replaced (fiddly but possible) if necessary without another epidural needed.

Suture loops (white) placed, starting to tighten orange string.

Catgut used for loops, white tape for lace. Ready to tighten.

COMMENTS

• Better to leave in place too long rather than not long enough. I generally suggest about a week.

• Once a vaginal prolapse is replaced you should feel the state of the cervix. Generally this is closed and

the chances of infection are much reduced.

• Vaginal prolapses show as a round, red, smooth protrusion unlike the cervical one pictured above.

• With the cervical prolapse pictured above on the left you can see that the cervix is already opening and

the chance of infection is high. In that case the calf died and the cow needed assistance to calve the

following day.

• Occasional neglected cases need to be euthanased if replacement is impossible. If the cow has not

calved a “bush caesar” is definitely worth a try. This involves getting the cow shot and immediately

extracting the calf via a hasty abdominal incision – hopefully still alive.

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Richard’s cow

This farmer kept a few Hereford cows to graze the gullies. They were notoriously fat and every

season there was at least one with a vaginal prolapse before calving.

I was presented with the cow pictured below. I said I hoped she wasn’t the one I had treated the

previous season. They said she had been culled. Then I found the scars from the previous suturing!

They had culled the wrong cow! She had outdone herself this time and had a rectal prolapse as well

as a vaginal one.

I put a purse-string suture in the anus and the shoe-lace suture in the vulva as shown above on left.

Richard’s cow with a rectal and vaginal prolapse.

She was due to calve in several weeks.

The cow did well for a few weeks but then blew the whole lot out again. This time I was unable to get

an epidural to work and couldn’t replace the vaginal prolapse. Time to go! Richard called the local

butcher. The butcher shot the cow and then he and I leapt over the fence – the butcher to bleed the

cow and me to extract the calf. But I had to wait for my turn as the butcher carefully made a mid-line

incision so as not to ruin the skin. With death throes going on above our heads it was finally my turn to

slash open the abdomen, locate the uterus and extract the calf. A live heifer!

A different case shown above. Neglected case impossible to replace.

Necrotic cervix with obvious line of demarcation. Unusually, the cow had calved months before.

.


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RECTAL PROLAPSES

• Very uncommon.

• Usually relatively easy to replace.

• Epidural needed for suturing.

• Purse-string suture round the circumference of anus will hold it in place. Leave a large finger-sized hole.

I use chromic gut suture but any absorbable suture of large size is ok.

• No need to remove suture if absorbable used, unless it’s causing a problem.

• In a neglected case amputation of the protruding rectum may be necessary. This procedure is detailed in

the “Diseases of Cattle in Australasia” textbook.

• An allergic response to tylosin injections can cause a swollen anus which resembles a small prolapse.

Stopping the tylosin treatment may be necessary. If the irritation is severe an epidural and anti-

inflammatories could be used. Replacement and suturing are not necessary.

Fat steer with easily replaced rectal prolapse.

Large animal memories: Tanner

Ross’ best mate was a white English bull terrier. I’d often see him riding round on the back of the

farm bike with Ross. He would come galloping out to greet me on the farm and he was just a big

ball of muscle. I had to be careful not to be knocked over. One of his thrills in life was eating horn as

I pared it off lame cow feet. This got to be rather dangerous (for Tanner’s mouth) and distracting (for

me) so sometimes I would tie him to the fence with a calving rope to work uninterrupted.

Documents

PROLAPSES - cdn.ymaws.com · get up. But it is not necessarily the prolapse that killed her. 5. A warning! After a difficult prolapse (some can take up to an hour or so of kneeling