Received: 26 July 2023 | Accepted: 27 July 2023 DOI: 10.1111/eve.13874


C L INI C A L COMMENTA RY


Decision- making in complicated dystocias Jarred Williams


| Robyn Ellerbrock Large Animal Medicine , University of Georgia , Athens , Georgia , USA


Correspondence : Jarred Williams Email: jarred@uga.edu


In their case report in this issue, Sikorra, Berreta, Voermans and Robinson (Sikorra et al., 2024 ) describe the successful management of a mare in labour with entrapment of the bladder and small colon, a fascinating case. The fact that both mare and foal were successfully discharged from the hospital attests to the quick decision- making and immediate surgical intervention by this team of veterinarians. To summarise, an 11- year- old Thoroughbred mare presented in la- bour, with an estimated time of 1 h in stage two of parturition. Upon presentation, the mare had a red structure extruding from the vulva, which was described as resembling a ‘red bag delivery’ (i.e. prema- ture separation of the chorioallantois). The mare was immediately sedated, anaesthetised and positioned in dorsal recumbency. The red structure was incised, at which point it was determined that it was the inflamed mucosa of an everted bladder rather than the cho- rioallantois. This is a great first point to discuss. As covered by the authors in the case discussion, premature


separation of the chorioallantois is confirmed when the cervical star is observed on the chorionic surface, whereas the urinary bladder can be identified by the presence of ureteral openings. This is eas- ier said than done in an emergency, particularly one as harrowing as this. Although the authors state that the red structure was ex- truding from the vulva on presentation, the structure appears to be within the vulva in figure 1 of their report. The change in position of the structure could be due to the fact that the photograph used in figure 1 was taken after the mare was anaesthetised and rolled into dorsal recumbency. This may have allowed the bladder to move back into the vaginal vault. Regardless, one can reasonably surmise that determining whether the structure was an everted bladder or a prematurely separated chorioallantois was quite difficult. Given that the authors had mistaken the urinary bladder for premature separa- tion of the chorioallantois, they should have opened it immediately rather than taking the time to sedate, anaesthetise and position the mare in dorsal recumbency. So, the error was not in mistaking the bladder for the chorioallantois, but rather the action based on that


assumption. Fortunately, their decision to quickly anaesthetise the mare allowed them to properly identify the problem and rapidly perform the caesarean section. Ultimately, this decision led to an increased chance of the foal surviving. While it is easy to reflect and comment on decisions made in


an instant, that is not always the fair or reasonable thing to do. The defining moment of this case was the immediate decision to take the mare to surgery and bypass vaginal delivery. Perhaps this decision was forced because the bladder took up space within the vaginal vault, preventing vaginal delivery. While it is possible decompres- sion of the bladder would have allowed delivery of the foal, this would have been a monumental task with small colon prolapsed into it. Addressing this complication would have been time consuming, which would have negatively affected the foal. Fortunately, the authors recognised the need to deliver the foal as quickly as pos- sible before deciding what had to be done for the mare. No time was wasted in discussion. This is fundamental to dystocia manage- ment, as it is well documented that foal survival drastically decreases when stage II lasts longer than 60– 70 min (Byron et al., 2003 ; Norton et al., 2007 ). There are three options for delivery of a living fetus during a


dystocia: controlled vaginal delivery, assisted vaginal delivery and caesarean section. In a report by Freeman et al. ( 1999 ), the survival rate for mares undergoing a caesarean section without concurrent disease was 88% (51/58), with all mares undergoing an elective cae- sarean section surviving (10/10). In contrast, mares presenting with dystocia that were treated by caesarean section or assisted vaginal delivery had significantly lower mortality rates (15% and 14%, re- spectively) than those undergoing controlled vaginal delivery (29%). While one might conclude that caesarean sections (especially elec- tive) are great and controlled vaginal deliveries are not, this is a bit misleading. For owners with limited finances, controlled vaginal delivery may be the only option, even when factors such as fetal position and trauma to the mare could suggest that is not the case.


This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2023 The Authors. Equine Veterinary Education published by John Wiley & Sons Ltd on behalf of EVJ Ltd.


Equine Vet Educ. 2024;36:17–19. aaep.org/wiley-redirect | 17

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