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| It is important to not overlook the veterinarian ' s experience han-
dling equine dystocias. Those that infrequently manage these cases will not have as good of a feel for timing of correction, techniques for efficient correction, and the effects of applied force leading to tissue trauma. Spending too much time trying to correct a difficult malposi- tion and/or applying great force to do so, may result in increased soft tissue damage that can lead to complications such as haemorrhage, metritis, vaginal or uterine tear, peritonitis, sepsis, laminitis, future reproductive unsoundness and death. The authors of this case re- port demonstrated aptitude and experience in managing such a dif- ficult case quickly and efficiently. The primary postoperative goals are passage of the placenta,
management of infection and recognition and intervention of on- going haemorrhage to avoid the potential development of sepsis, endometritis, hypoperfusion and laminitis. If the placenta is passed quickly, the uterus may be lavaged as needed and involution aided by the administration of oxytocin. The authors of this case report dili- gently managed this mare post- operatively, recognised the potential for complications and appropriately and aggressively targeted these vital issues. Given the fact that the placenta had been retained for approximately 48 h, the authors ' decision to lavage the uterus makes perfect sense to us. In fact, some clinicians are comfortable lavaging the uterus within a few hours after surgery, relying on the strength of uterine closure to prevent leakage into the abdominal cavity. Alternatively, low- pressure, low- volume lavage using sterile isotonic fluids and the umbilical infusion technique (Meijer et al., 2015 ) after surgery may have resolved the retained placenta in a more timely manner. Ultimately, the decision of when to lavage is dictated by cli- nician preference, integrity of the uterus at time of surgery and the mare ' s systemic health. The ideal scenario after a caesarean section is survival of the
mare, delivery of a live, healthy foal and maintenance of her repro- ductive soundness. As Freeman et al. ( 1999 ) reported, however, the survival rate of foals delivered following dystocia was 11% at the time of delivery, which decreased to 5% by discharge. There was no difference in foal survival based on technique used to deliver the foal from mares with dystocia. The authors of this case report achieved two of the three desired outcomes, with the mare ' s repro- ductive soundness yet to be determined. Although the lives of the mare and foal obviously are every-
one ' s top priority, it is important to discuss the mare ' s reproductive soundness after caesarean section with the owners. In a report by Abernathey- Young et al. ( 2012 ), 77% of 95 mares previously had foaled before undergoing caesarean section. After caesarean sec- tion, the cumulative foaling rate 3 years later for those mares de- creased to 52% if the duration of dystocia exceeded 90 min. These findings reinforce the importance of rapidly identifying and address- ing dystocia to maximise the mare ' s future reproductive potential. This case study illustrates the remarkable degree to which the
external urethral sphincter can stretch; expanding from a normal diameter of an index finger to accommodate a folded small colon. This capacity should not be forgotten when managing horses that
WILLIAMS and ELLERBROCK
may need urethral dilation, such as replacement of an everted blad- der or prolapsed section of the gastrointestinal tract, or removal of a cystic calculi. It also facilitates creative thought for the poten- tial removal of a bladder tumour that may not be accessed via the abdomen. Finally, it is noteworthy, and likely fortunate, that the small colon
prolapsed into an intact, everted bladder. More commonly, the small colon prolapses through the rectum. Unfortunately, when this oc- curs, the small colon mesentery and associated vessels stretch with less impedance, creating unfixable rents and potentially rendering the small colon non- viable. In the present case study, the everted bladder represented a nice ‘bag’, so to speak, to contain the small colon and reduced the irreversible damage that could have occurred. This factor likely had an influence on outcome, however, unusual and rare it was. Sikorra, Berreta, Voermans and Robinson presented an interest-
ing case and are to be commended for a job well done. Additionally, this case allows all of us the opportunity to put ourselves into their shoes and think about what we would have done, while giving us a quick blueprint for if and when we come across a similar problem. As we know, we will not have the time to research when presented with a similar case, and we thank them for preparing us for that moment.
AUTHOR CONTRIBUTIONS Both authors made equal contribution to this clinical commentary.
CONFLICT OF INTEREST STATEMENT No conflicts of interest have been declared.
FUNDING INFORMATION No funding was received.
ETHICS STATEMENT Not applicable to this clinical commentary.
ORCID Jarred Williams
https://orcid.org/0000-0001-9873-0201
REFERENCES
Abernathey- Young , K.K. , LeBlanc , M.M. , Embertson , R.M. , Pierce , S.W. & Stromberg , A.J. ( 2012 ) Survival rates of mares and foals and postoperative complications and fertility of mares after cesarean section: 95 cases (1986- 2000) . Journal of the American Veterinary Medical Association , 241 , 927 – 934 .
Byron , C.R. , Embertson , R.M. , Bernard , W.V. , Hance , S.R. , Bramlage , L.R. & Hopper , S.A. ( 2003 ) Dystocia in a referral hospital setting: ap- proach and results . Equine Veterinary Journal , 35 , 82 – 85 .
Freeman , D.E. , Hungerford , L.L. , Schaeffer , D. , Lock , T.F. , Sertich , P.L. , Baker , G.J. et al. ( 1999 ) Caesarean section and other methods for assisted delivery: comparison of effects on mare mortality and complications . Equine Veterinary Journal , 31 , 203 – 207 .
Meijer , M. , Macpherson , M.L. & Dijkman , R. ( 2015 ) How to use umbilical vessel water infusion to treat retained fetal membranes in mares . Proceedings of the American Association of Equine Practitioners , 61 , 478 – 484 .
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