Finally! A Prolapse with Pictures!

I was on call this past weekend and had quite an array of calls. The first was for a left DA; pretty routine procedure that went well. The second call was for a weak goat that, after performing a fecal, was found to be loaded with intestinal parasites (worms). He was treated with electrolytes, dewormed and sent home. Hopefully he had not lost so many nutrients and blood from the worms that he is able to recover after a couple rounds of dewormer.  The next call was for a cow that had calved earlier that day and suffered from a uterine prolapse.  The final call of the weekend was a calving. 

I know I’ve discussed other emergency calls where I’ve had to attend to a prolapse, but never had any pictures to show you what it really is. When I arrived at this farm, the cow was out in the pasture and I had to have them run back to the barn to get water, so I had some time to actually take a picture!  

Uterine prolapses are one of the few TRUE, emergency- drop- everything -and – come calls that we get in dairy practice. This condition usually occurs in older cows that have already had one or two calves. It can happen in first time mothers, but is not quite as common.  Normally prolapses will occur within the first 24 hours after a cow has had a calf. If she has made it through the first 24 hours without any trouble, it is pretty rare that she will prolapse at that point.

For those that have never seen a uterine prolapse, it is when the entire uterus, which I remind you just had an 80+ pound calf inside it, completely inverts and falls outside of the vagina. It is the uterus, inside out, outside the cow. Sometimes the bladder will also come out with it, and in really bad cases, there may be some loops of intestines that also have prolapsed. 

 In the picture you can see these large “lumps” on the uterus.  These lumps are called the “caruncles” and are the attachment points of the placenta (cotyledons) for the calf.   The best analogy I can come up with for a uterine prolapse, is a pair of pants that you have taken off, and instead of grabbing the ankle and pulling, you start at the waist and completely turn them inside out. 

Prolapsed uterus

There is no definitive “cause” of a uterine prolapse; however there are certain conditions that predispose cows to prolapse.  A difficult calving where the cow strains a great deal, continues to strain and/or has a very large calf, will predispose a cow to having the uterus prolapse, as well as when the cow is hypocalcemic (low blood calcium). Calcium plays a role in smooth muscle contractions in the body. The uterus is considered a “smooth muscle” organ, so when the cow is low on calcium in her blood, the uterus is not contracting down like it should, after the cow has calved.  

Some of the biggest concerns we have about cows with a uterine prolapse is shock due to blood loss, traumatic damage to the uterus as it is outside the cows’ body, and entrapment of the intestines in the inside-out uterus, causing an entirely different issue.  The uterus is suspended in the cow from two ligaments that attach to the side if the body. Inside each of these ligaments is a major vein and artery.  As the uterus is prolapsing, turning inside out, headed out of the vagina, it stretches these ligaments and therefore the veins and arteries inside them.  The concern is when they have been stretched to the point that they have ripped and as tension is released on these vessels, the cow starts bleeding internally and can easily bleed to death in a short time.

So how do we take care of this 50+ pound organ that is supposed to be inside the cow that is now outside??? Well, first and foremost we give the cow an epidural, or spinal, to prevent her from feeling the procedure and also to prevent her from continuing to push and strain against us as we try to replace the uterus.  The cow can be standing while we fix her, or can be laying down with both back legs extended directly behind her. We then wash the uterus being sure to remove as much bedding, mud, debris, etc. from the uterus as possible.  

Now back to the pant analogy.  We can fix the pants by going from the waistband, back down the leg, grab the cuff and pull it back up through. Well in a cow, we can’t jump inside the cow, and reach from the inside to the tip of the uterus and pull it back through. Instead, we have to start gently pushing the uterus back in, starting close to the vulva and working it back inside. It would be like starting with the cuff of the pants and pushing it back through to the waistband.

As we are pushing the uterus back, we have to be sure not to rip off any caruncles, or push our fingers through the sensitive and damaged uterine tissue.   If a tear does occur, then we can suture the hole and continue on. It’s just better if we avoid making a hole in the first place. 

Replacing the uterus is quite a workout, if I do say so, but I can replace a nice “easy” prolapse in about 20 minutes.  I have also worked on them for over an hour  only to have the cow push it back out just as I have it almost all the way in.  The longer the uterus is prolapsed, the more edema the uterus will get, it can dry out and become less pliable and can be severely injured from other cows or herself.  When a cow does have a uterine prolapse, we recommend the farmer keep her quiet, keep other cows away from her, and try to keep the uterus as clean and moist as possible until we can get there. 

After the uterus has been pushed back inside the body, we have to make sure it is completely everted so it doesn’t re-prolapse. We then give the cow an injection to help with the smooth muscle contraction and shrinking the uterus back down so it can’t come back out.   Finally we give the cow some calcium in the jugular vein and start her on antibiotics in case we didn’t get every little spec of dirt off the uterus before we replaced it. 

Some practitioners will place a “buhner stitch” in the cow’s vulva after replacing the uterus.  It is a stitch that essentially closes the vulva up and allows only enough room for her to urinate. As a practice we have decided to do this, but it really is more of a placebo effect for the farmer.  If the uterus was replaced properly, and the cow was given the appropriate medication to start the uterus shrinking back down, there is no need for this stitch.  If the uterus was not replaced correctly and the cow continues to strain, or the medications were not given to start the uterus shrinking back down, she can re-prolapse and this stitch will do nothing to stop it.  For the cows that do have a buhner stitch placed, it is removed about 4-5 days later.  The picture shows the stitch placed after I replaced the uterus on this cow. 

Buhner Stitch Placed

This cow stood during the entire procedure and walked to another part of the pasture and started eating when we were done.  I think she will be fine and should breed back in a few months with no issues.