Case report

Fetotomy and wound treatment

Date: 2008

Place: Rotterdam Zoo

Data provided by: Willem Schaftenaar

History

A 37 years old matriarch Asian elephant failed to deliver her 5th calf. At 13 months from the failed parturition, a herd mate of this animal delivered a healthy full-term calf. The calf tried to nurse from the matriarch and this elephant actively encouraged the calf to do so. Within 6 hours of this behavior, the matriarch displayed intense labor. After 24 hr, the hind legs of the retained calf could be palpated transrectally in the vagina, and several sharp fetal bone fragments (dorsal spines, fractured ribs) were palpated as they almost penetrated the vaginal wall. At that time, the animal was completely exhausted and contractions had ceased.

With a failed attempt to extract the fetal carcass through the intact birth canal using two Krey-Schöttler fetotomy hooks, a decision was made to perform a vagino-vestibulotomy.

Onset of labor 6 hours after the birth of a calf in the herd

Six hours after the birth of a calf in the herd, labour in the matriach started, 13 months after the first signs of labour had come to a stop.  

Treatment

The animal was chained on one front leg and the opposite hind leg. 150 mg xylazine was slowly hand-injected intravenously. During the entitre procedure (11 hours) extra doses of 75 mg xylazine were given intravenously every 50-60 minutes. Four 4 local depositions of 20 ml Lidocain 2% (with adrenaline) were injected in the midline below the anus. Epidural anesthesia was not used, however  new insides have proven that this is an important method to reduce movement of the tail and decreases pain perception in the perineal region. The animal remained standing throughout the entire procedure. A 15cm skin incision was made in the midline. A rubber (cattle) stomach tube with a 10x60mm window at the tip was inserted in the vestibulum vaginae and advanced till the tip reached the dorsal edge of the incision. The vestibulum vaginae was incised over the window of the tube.

The legs of the calf could be visualized in the horizontal part of the vagina. At least 4 fractured ribs were found, probably fractured by the natural contractions of the uterus duting the past 24 hours. The fractured ends had penetrated the wall of the vestibulum on the left caudo-ventral side, but not completely perforated, resulting in several tears of the mucosa (20cm long). The roof of the vestibulum vaginae had some mucosa tears too, also not perforating the wall totally.

The carcass was cut into more then 100 large pieces; many ribs were removed one by one to avoid damage to the wall of the vestibulum vaginae. A complete fetotomy was performed using a Thygesen fetotome (Utrecht model). Finger knifes, Krey Schüttler hooks, saw directors and calf delivery chaines were used to cut the carcass in smaller lieces and pull them out. Large pieces were pulled out with extra support by a calving-pully for cattle. A long blunt "eye-hook" (used to grab a dead cattle or horse fetus in the orbit) was modified at the spot making it a prolonged knife (like a "finger knife" for fetotomy). Muscles were split from their bone attachment using this knife and blunt fingers. Lumbs of the carcass that were too big to pass through the fetotomy opening, were removed via the normal birth canal.

 

After 3 hours 40 ml Duphaspasmin (11.58 mg isoxsuprinelactate per ml, Fort Dodge NL8514) ws injected i.m. followed 30 minutes later by another 40 ml Duphaspasmin i.m. as well as 100 ml Amoxicilline 20% (200 mg amoxicilline trihydrate/ml, NL 2795) i.m.

 

After 9 ¾ hours the entire carcass of the fetus was removed. 5 ml Oxytocin (oxytocine 10 IU/ml, NL3852) was given intravenously. The uterus was flushed with large amonts of luke-warm water using a plastic hoose pipe. The water was drained as much as possible. Ten liters of 0.09% NaCl was brought into the uterus using a cattle stomach tube and a funnel.

Thirty minutes after the previous injection, another 5 ml Oxytocin (oxytocine 10 IU/ml) was given i.v. The uterus started to show moderate contraction on the ventral side. The rest of the uterus was still filled with air. A custom-made balloon (100 ml volume) catheter was advanced into the urinary bladder. The mucosa of the vestibulum vaginae was sutered with 2/0 PDS, continuous Cushing stitches. The overlying muscular tissue and connective tissue was sutured in 2 layers using) Vicryl, continuous stitches. Only the dorsal 5 cm of the skin was sutured intradermally using 1 Vicryl, single stitches.

The mucosa of the vulva and the distal part of the vaginal vestibule had been severed by the passage of large lumps of the carcass with sharp bony edges.

A 84 kg female calf carcass was removed in more than 100 pieces. The carpal joints were in flexed position and could not be bent unless the flexor tendons were cut thorught. This condition is known as arthrogryposis. Whether this had caused the initial dystocia remains inclear.

 

Antibiotic treatment (150 ml amoxicilline 20%, i.m. SID) was given for 9 days.

The balloon catheter came out one day after the fetotomy. During the following weeks the vulva and vaginal vestibule became heavily infected and large pieces of necrotic tissues were lost. After 5 days transrectal ultrasonographic examination demonstrated that there was still a lot of detritus in the uterus. Five ml. of oxytocine (10 IU/ml) was given i.m. Surprisingly the uterus was still responsive to oxytocine, as aftre a few hours a lot of fluid was discharged through the vulva. When this was repeated 2 days later, no reaction of the uterus was observed.

Making an incision in the vaginal vestibule guided by a plastic tube (with a window cut out) advanced in the vaginal vestibule.

The Thygesen fetotome is advanced into the horizontal birth canal.

Most parts of the fetus were removed through the vulva, which allowed a relatively small incision of the vaginal vestibule 

Krey-Schüttler hook

Thygesen Fetotome

Giggli saw director

Custom-made balloon catheter

Finger knife

Pieces of the carcass were put together to check whether bones were missing. One femoral condyl was missing. It was found the following day. Note the arthrogryposis in the right carpal joint. The left carpal joint is stretchted after cutting through the flexor tendons. 

Treatment results

All sutures came off after 14 days, which facilitated the daily treatment of the distal part of the birth canal: flushing with 50-100 liters of 0.09% saline solution through the surgical wound. This treatment was continued for several weeks. Six weeks after the fetotomy, the elephant was sedated again with xylazine, and the necrotic area of the surgery wound was debrided. In the following weeks, the surgery wound and the wounds in the distal part of the birth canal started to heal nicely.

 

Ten weeks after the fetotomy the surgery wound had reduced in size from 15cm to 10 cm. Flushing with saline water was discontinued.

At 14 weeks the surgery wound was 5.7 cm long.

At 5 months the skin and mucosa of the vaginal vestibule had fused completely, leaving a 4 cm opening. The elephant was sedated again with xylazine and the skin-mucosa fusion was surgically disconnected. Over a circular area of 4 cm around the opening, the skin was seprated from the vaginal vestibule. The vaginal vestibulum was closed in 2 layers using 2/0 Moncryl; first layer: Schmieden suture; second layer: Lambert suture. The skin was left open. All sutures came off after 5 days. It was decided to allow the wound to heal per secundam. The wound was flushed with saline solution on a daily base. Two months later, the wound diameter was 4 cm and the epithelization between skin and mucosa was complete again.

 

One year after the fetotomy the opening was still 4 cm. Standing sedation was performed using xylazine. The tissues around the fistula were injected with a total amount of 17 ml Lidocain 2% (with adrenaline). A small strip of the epithelium layer that formed the edges of the fistula was cut off and the subcutis was incised, separating the vestibulo-vaginal wall from the skin over 2-3 cm.

The vestibulo-vaginal wall was closed using Vicryl 1, continous Utrecht-uterus suture. Antiseptic, silver impregnated gauze was inserted in the subcutaneous space. The gauze was sutured to the ventral edge of the wound using Vicryl 1 to facilitate later removal. The skin was closed using a continuous intracutaneous suture (Vicryl 1). Three extra single matrass sutures (Vicryl 6) and 1 single suture were applied as an extra support for the intracutaneous sutures. The ventral part of the fistula was left open to allow later removal of the gauze.

9 days after wound dressing: all sutures came off. The vaginal wound is retracting in the subcutaneous space (thus enlarging the wound surface). Diameter of skin wound: 6 cm.

15 months after fetotomy:wound almost closed, leaving a permanent opening of 3 mm,

Wound healing

Severely swollen vulva 3 days after the fetotomy.

Two months after the fetotomy, the wound starts healing nicely.

Necrotic tissue protruding through the vulva, 12 days after fetotomy.

Five months after the fetotomy, epithelization of the edges of the skin and mucosa has interrupted wound healing

Five months after the fetotomy, wound dressing is performed. The vaginal vestibule is closed. Photo taken before closing the skin.

Five days after the surgical wound correction, all sutures came off.

One year after the fetotomy, a second wound dressing is performed. One week later, the wound opened and the succutaneous drain came off.

Eighteen months after the fetotomy, the wound was closed, leaving only a 3 mm opening (black structure above the pink connective tissue area.

Conclusion of the author: the skin should not be sutured after a vestibulotomy or a fetotomy in elephants, as it delays the healing process. Closing the vaginal vestibule is also questionable, as the mucosa around the surgical wound is heavily contaminated by the strong manipulations needed for the procedure, resulting in wound infection. Healing per secundam of the entire wound is recommended, no matter how hard it is for a vet to leave such a big wound open!