Raksha Technical Bulletin June 2011, 2:11-17

Diagnosis and correction of uterine torsion in cattle and buffaloes

G N Purohit, Yogesh Barolia, Chandra Shekhar and Pramod Kumar Department of Veterinary Gynecology and Obstetrics College of Veterinary and Animal Science Rajasthan University of Veterinary and Animal Sciences Bikaner, Rajasthan

Abstract The clinical findings, diagnostic approach and correction of uterine torsion in cattle and buffaloes are described. Retrospective analysis of uterine torsion in cattle and buffaloes at our centre is also mentioned. Key words: Buffaloes, cattle, cesarean section, rolling, uterine torsion. Introduction: Uterine torsion is one of the frequent maternal causes of dystocia in river buffaloes and cows that commonly occurs near parturition and less commonly during gestation. The entire length of the pregnant uterine horn rotates on its longitudinal axis to the left (anti-clockwise) or right side (clockwise). The fetus and its membranes also rotate with the uterus; there is compression of the blood supply to the fetus, hemorrhage or seepage of blood in the alantoic cavity and resultant death of the fetus in utero. Since uterine torsion frequently occurs during parturition, the birth canal is occluded because of twisting and delivery of fetus cannot occur. Uterine torsion is a diagnostic dilemma for veterinarians and a difficult obstetric procedure for less experienced persons. The diagnostic criterion and correction procedures are mentioned here. Clinical findings When uterine torsion occurs at the time of parturition the first clinical finding noticed by animal owners is non-progression of labor. The animal may show signs of parturition with frequent getting up and lying down, colic pain but in most of the cases the labor does not progress and neither fetal bags, fetal fluids or fetus itself appear at the birth canal. The degree of torsion may vary from 900 to 3600. Depending upon the degree of torsion the chances of presence of fetus in the birth

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canal vary. In smaller degree torsions, sometimes parts of the fetus may be present in the birth canal and one or both water bags might have appeared at the birth canal and ruptured. However, the torsions are usually 1800 or more and in these cases nothing appears at the birth canal. The parturition signs would become weak if the torsion is not corrected quickly. In mid gestation the animal would show colicky signs and signs of an impending parturition. The animal may show varying degrees of shock or toxemia that may occur if torsion occurs after cervical dilation. Partial anorexia, dullness and depression may be evident. Restlessness and arching of back may be evident in buffaloes. Diagnosis Uterine torsion should be suspected if an animal has a history of non-progressive labor. The point (place from which uterus rotates) of torsion could be just cranial to the cervix (pre-cervical) or caudal to the cervix (post-cervical) and the side of torsion can be right or left. At our centre we found that torsions are generally towards the right side and mostly pre-cervical both in cattle and buffaloes (Table 1). The diagnosis of the side of torsion is extremely important as this decides the side of rolling of the animal for torsion correction. In some of the cases one or both lips of the vulva are pulled in to one side (Fig 1) because of the twisting of the uterus caudal to the cervix but this is not essential and clinicians must not rely only on this finding as this may be more evident in higher degree post-cervical uterine torsions only and absent in precervical uterine torsions. Vaginal and rectal examination helps in diagnosis. Vaginal examination reveals twisting of the vaginal mucus membranes. The side of the twist determines the side of torsion. The hand cannot be passed deeper into the anterior vagina which has a conical end in torsions with degree of torsion being 1800 or more. In lesser degree torsions however, the fetus can sometimes be felt. Clinicians often confuse such finding with cervical non-dilation. However, in such cases when the hand is passed further in the birth canal, the fetus may be found twisting to one side along with the uterus also being felt twisted. The twisting of vaginal mucus membranes is not always present even in post-cervical uterine torsions and hence the most useful diagnostic parameter for uterine torsion is recto-genital palpation. By rectal palpation, the location of the broad ligaments is assessed and this is the best diagnostic indicator of uterine torsion both in cattle and buffaloes. At our centre 64.3% and 83.6% of cattle and buffaloes respectively evidenced pre-

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cervical uterine torsion which could be diagnosed only by rectal palpation. The broad ligaments are the only holding structures of a gravid uterus on both the sides and when a uterus rotates the broad ligaments also rotate. The broad ligaments can easily be felt by rectal palpation. Both side ligaments are small bands of tissue felt as straight structures. When the pregnant uterine horn rotates to one side, the nonpregnant uterine horn which is closely attached to the gravid uterine horn by the inter-cornual ligament would also rotate to the same side (Fig 2 and 3). Thus, the location of both the broad ligaments is changed in uterine torsion. When the uterus rotates to the right side (This is ascertained by standing at the caudal side of the animal. One should face the birth canal and determine the right or left side standing here) the right broad ligament goes under the uterus whereas, the left ligament is pulled towards the right side and can be felt as a crossing structure (Fig 2 and 3). When the uterus rotates towards the left side (the side of the rumen) the left broad ligament can be felt going under the uterus and the right ligament can be felt crossing towards the left side. In every case of uterine torsion rectal palpation should be done to ascertain the presence of torsion and the side of torsion. It is difficult to exactly determine the degree of torsion especially in torsions greater than 90-1800 by both vaginal and rectal palpation although with experience clinicians can approximately predict the degree of uterine torsion. It is pertinent to record the general condition of the patient and the time since torsion as this would determine the correction options to be adopted. Torsion correction Uterine torsion is an obstetrical emergency and hence attended on priority. It is essential to bring back a twisted uterus to its normal position (and this is known as detorsion) when torsion occurs during mid-gestation or when it occurs at parturition and vaginal delivery is desirable. A fetus in a twisted uterus cannot live for long because of compression of the blood supply and at times placenta and it cannot be delivered through the birth canal until the twist is very small (30-450). Smaller degree torsions may sometimes be corrected spontaneously. The general condition of the patient must be improved before detorsion is attempted especially if the torsion is existent beyond 36 hours and the animal suffers from shock and toxemia. Appropriate fluid replacements, antibiotics and corticosteroids should be given to such animals. Three approaches of torsion correction are possible i) rotation of the fetus per vaginum ii) rolling the cow or buffalo and iii) laparohysterotomy.

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Rotation of the fetus per vaginum is possible only in mild degrees of torsion where the obstetricians hand can touch the fetus and sufficient fluids are present in the uterus (Jackson, 1995). The fetus is grasped by a bony prominence such as elbow, sternum or thigh and swung from side to side before being pushed right over in the opposite direction of torsion. If both fetal limbs are palpable they can be tied in the cuffs of caemmerers torsion fork or a Kuenhs crutch and an assistant can rotate them. If the manipulation is successful, the torsion will disappear and the vaginal folds will regain normal shape and the fetus can be delivered with little difficulty. However, sufficient lubrication must be available in the birth canal and uterus before attempts at rotating the fetus are made using instruments. When sufficient time has passed since the onset of such a problem, the uterus will tightly contract around the fetus and detorsion with this method is not possible. Rolling the cow or buffalo utilizes the principle to roll the animal around its uterus while the uterus remains static. It is one of the oldest and simple methods to relieve uterine torsion in cows and buffaloes. The animal must be rolled preferably on grass with its head lower than the rear quarters. Vicious animals must be given a sedative. The animal is laid down in lateral recumbency on the same side to which the torsion is directed. The two hind legs are tied together by a rope. Both the fore legs are also tied together using a separate rope. The animal is rolled suddenly (in the same direction towards which side the uterus is twisted) to the other side. The rapidly rotating body of the cow/buffalo overtakes the more slowly rotating gravid uterus. After the animal has been rolled to 1800 her body must be brought back to the original position slowly so that she can be rolled once again. After two rolling, the birth canal should be examined to determine whether the torsion is corrected or not. If corrected properly, the spiral folds and stenosis of the birth canal would disappear and if the cervix is dilated, the fetus can be palpated with ease. Plenty of blood stained fluid comes out of the birth canal if the cervix is open and this is sufficient evidence of correction. If the torsion is not corrected, the rolling procedure should be repeated 3 or 4 times. If after 4 attempts, the torsion is not corrected, then other procedures for correction of torsion must be considered as uterine rupture can result due to violent rolling ( Prabhakar et al., 1997; Singh and Dhaliwal, 1998). Although, torsion may be corrected by rolling in patients of not more than 36 hours duration, the potential dangers of uterine rupture with continuous rolling must always be kept in mind. If the vaginal folds are increasing after a rolling, the rolling must be done on the opposite side. Sometimes, after the correction of torsion, it may take 12 hours or more for the cervix to dilate, and hence one should not be overenthusiastic in removing the fetus after torsion

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correction. Prostaglandin injections are suggested if the cervix is not dilated. Fetuses are delivered 12-24 hours after a prostaglandin injection. A modification of the rolling technique called Schaffers method, has been described by Arthur, (1966) and recommended widely for detorsion of uterus in cows and buffaloes. In this method, a slightly flexible wooden plank of 9 to 12 feet long and 8 to 12 inches wide is placed on the recumbent cows flank with the lower end of the plank on the ground. An assistant stands on the plank while the cow/buffalo is slowly turned over by pulling the ropes (Fig. 4 and 5). A slight modification of this method has been suggested for the buffalo (Prakash and Nanda, 1996). The advantages of this technique are that the plank fixes the uterus while the cows body is turned and that, because the cow/buffalo is turned slowly less assistance is required and it is easier for the veterinary surgeon to check the correct direction of the rolling by vaginal palpation (Purohit, 2006). Usually, the first or second rolling is successful (Arthur et al, 1996). At our centre rolling was successful in torsion correction only in 55.5% and 36.8% of cattle and buffaloes. Similar methods have been used with varying degrees of success in the buffalo (Pattabiraman et al., 1979; Prasad et al., 2000; Matharu and Prabhakar, 2001). It is considered that since buffaloes have a capacious abdomen more pressure is required on the free end of the plank that is being modulated by an assistant resulting in better detorsion compared to the Schaffers method (Singh and Nanda, 1996). However, it more depends on the time of correction since torsion onset. The number of turns required in buffaloes are more (2.5) compared to cattle (1.0) (Pattabiraman et al., 1979) and vaginal delivery takes a longer time after detorsion. Buffaloes with fully dilated cervix at detorsion have maximum survival and detorsion failure occurs in 20% of the cases using rolling method (Nanda et al., 1991). In the authors experience, detorsion failure is common in cases presented beyond 36 hours of delay and in animals where dead emphysematous fetus is present or uterine adhesions or uterine rupture is present. Similar views have been expressed by other workers (Dhaliwal et al., 1993; Prasad et al., 1998). It is known that detorsion is difficult in the presence of a dead fetus (Prabhakar et al., 1994). Laparohysterotomy is suggested in cases of uterine torsion that fail to be corrected by rolling or in long standing cases where fetus is dead and uterine adhesions/rupture are likely. The outcome of a caesarean when the fetus is dead and emphysematous can be grave. It is advisable to take care of the patient for the general condition before deciding to operate. Caesarean is a method of choice in cases presented with a closed cervix, dead fetus with subsided symptoms of parturition. It is better to administer plenty of fluid therapy, antibiotics and corticosteroids before starting the operation. Different operative sites for caesarean

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are suggested including the right or left flank (Fig 6), midline (on or parallel to linea alba), horizontal incision above arcus cruralis, or appropriate incision in the right or left lower flank or an oblique ventrolateral approach with the animal in right lateral recumbency (Purohit, 2006). The authors consider the left oblique ventrolateral approach (Fig 7) with the animal in right lateral recumbency (Fig 8) as a better operative site as it results into minimum post operative complications (Purohit and Mehta, 2006). The anesthesia usually required is mild sedation with local infiltration. During the laparohysterotomy, the uterus is brought to the site of incision by holding a fetal extremity and incised. The fetus is removed with due care. Because of the fetal death and the consequent uterine adhesions that develop in cases operated beyond 36 hours it is not many times possible to detort the uterus before the removal of the fetus. At times it is not even possible to bring the uterus to the site of incision in such cases. Many times if the animal had uterine torsion, rupture of uterus can occur subsequent to attempts at correction of torsion by rolling. Such ruptures must be searched during the operation and if possible repaired. If the tear is not within approach, the best option is to inject 20-40 I.U oxytocin within the uterine wall at 3-4 or more locations to contract the uterus. The abdominal would is closed routinely. Prognosis The prognosis of uterine torsion is good when correction is done early. In cases treated beyond 36 hours the chances of fetal survival are negligible. At our centre only 7.1% (2/28) of calves and 6.12% (3/49) buffalo calves could be delivered live because of the reason that majority of the cases were brought after 36-48 hours of uterine torsion. The dam survivability is high with rolling but comparatively lower with cesarean section because of poor patient condition and operative or postoperative complications. Similar findings have been previously recorded (Prabhakar et al., 1997; Singh and Dhaliwal, 1998). In conclusion uterine torsion must be attended on priority with sufficient care of the general condition of the patient and rolling of the animal in the right direction. When 3-4 rolling fail to correct the torsion cesarean section must be done immediately.

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Table 1 Type of uterine torsion and the outcome of correction in cattle and buffaloes at Veterinary College, Bikaner between 2003 to 2010.
Animal Num Side of Place of torsion ber torsion of Postcase Left Right Precervical cervical s Correction method
Rolling CS

Fetal viability Maternal after viability correction

Live Dead Rolling CS

Cows

28

24

18

10

10

18 2

26

9/10

14/18

Buffaloes

49

48

41

20

29 3

46

16/20 24/29

References
Arthur GH (1966). Recent advances in bovine obstetrics. Vet. Rec 79: 630. Dhaliwal GS, Prabhakar S, Sharma RD (1993). Torsion of pregnant uterine horn in a cow. A case report. Indian J Anim Reprod 14: 129.
Jackson PG G (1995). Eds Dystocia in the cow: In: Handbook of Veterinary Obstetrics. W.B. Saunders Co. Ltd. Philadelphia. Pp. 30-69. Matharu SS, Prabhakar S (2001). Clinical observations and success of treatment of uterine torsion in buffaloes. Indian J Anim Reprod 22: 45-48. Nanda AS, Sharma R D, Nowshahari M A (1991). The clinical outcome of different regimes of treatment of uterine torsion in buffaloes. Indian J Anim Reprod 12: 197-200. Pattabiraman SR, Singh J, Rathore SS et al (1979). Non surgical method of correction of bovine uterine torsion- A clinical analysis. Indian Vet J 56: 424-428.

Raksha Technical Bulletin June 2011, 2:11-17 Prasad S, Singh OV, Dabas YPS et al (1998). Clinical management of delayed uterine torsions of more than 360 in buffaloes. Case reports. Indian Vet J 75: 890-891. Prasad S, Rohit K, Maurya SN (2000). Efficacy of laparohysterotomy and rolling of dam to treat uterine torsion in buffaloes. Indian Vet J 77: 784-786. Prakash S, Nanda AS (1996) treatment of uterine torsion in buffaloes- modification of Schaffers method Indian J Anim Reprod 17: 33-34. Purohit GN (2006). Maternal causes of dystocia in cows and buffaloes. In, Suresh SH, Tandle MK eds. Veterinary Obstetrics A Practical Guide Jaypee Brothers Medical Publishers New Delhi p 16-25. Purohit GN, Mehta JS (2006) Dystocia in cattle and buffaloes: A retrospective analysis of 156 cases. Vet Pract 7:31-34. Prabhakar S, Singh P, Nanda AS et al (1994). Clinico obstetrical observations on uterine torsion in bovines. Indian Vet J 71: 822-824. Prabhakar S, Dhaliwal GS, Sharma RD et al (1997) Success of treatment and dam survival in bovines with precervical uterine torsion Indian J of Anim reprod 18: 121-23 Singh J, Dhaliwal GS (1998) A retrospective study on survivability and fertility following cesarean section in bovines. Indian J Anim Reprod 19:21-23 Singh P, Nanda AS (1996). Treatment of uterine torsion in buffaloes. Modification of Schaffers method. Indian J Anim Reprod 17: 33-34.

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Fig 1 Uterine torsion affected buffaloes showing twisting of vulvar lips

Fig 2 The position of a normal uterus and uterus with torsion

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Fig 3 The position of a normal uterus and uterus with right or left side torsion. The position of the broad ligaments is shown.

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Fig 4 The placement of the plank on a cow during rolling by Schaeffers method for uterine torsion correction.

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Fig 5 Placement of a plank over the flank before rolling a buffalo for torsion correction

Fig 6 The left flank laparotomy site for cesarean section in a buffalo

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Fig 7 The Oblique venterolateral operative site for cesarean section in a buffalo.

Fig 8 A buffalo casted in right lateral recumbency for cesarean section