So this webinar covers the management of uterine prolapses in ruminants, and we'll consider not just the physical active replacement, but we'll consider predisposing factors, reducing the risk of recurrence, reducing the risk of recurrence in the first place, and The advice that we really should be giving our clients when we attend the uterine prolapse. So I'm David Charles, an experienced production animal vet and a RCV as accredited advanced practitioner. And as I say, in this session, we will understand the likely causes of uterine prolapses in adult ruminants.
And then firstly we'll look at cattle and we'll make sure that by the end we can describe the steps to appropriately correct a bovine neutron prolapse. That you can discuss appropriate pre and post-procedural treatments for the cow with the client. And it's important that we understand the prognosis for these cases and the economic impact so that we can be giving the best case by case advice to our clients.
After that, we'll consider sheep and by the end we should be able to discuss the differences in the approaching medications for adult use with uterine prolapse compared with. What we've covered earlier in the talk considering adult cattle. And For any farm animal practitioner.
Do you try and prolapse is always the case that sticks in the mind often might conjure up some. Very dynamic, very eventful cases that we've seen and managed as they can present in so many different ways. And for me, this is the one I always think of when I go to an utron prolapse where I'm educating vets and students like utron prolapses.
It's an infamous after hours or emergency call. But how common actually are they? What's the prevalence of bovine neutron prolapses?
Well, the good news is they're probably not as common as we may think. The literature shows us. That it's between 0.002 and 1% of all carvings result in the uterine prolapse, remembering that the uterine prolapse is seen after carving.
And for instance, If we then look at specifically dairy cows versus beef, well, it's more common in a beef cow compared with dairy cattle, so. May reach heights of 1% in beef, but colleagues here found an average of 0.6% in dairy.
That study had almost 33.5 1000 calving cows in it, so it's a sizable data set to give good reliance for prevalence data, and that probably fits with what we see in practise. While they're memorable, and that's something that we're all Know well, often they do come out of hours.
It's not the most common out of hours call at all. So fitting with what we see in practise. And it's good to start at the beginning and consider the risk factors for uterine prolapse.
And in cattle, We know age is a factor, particularly animals over 3 years old. We know breed can be a risk factor for you trying prolapse, as I say, more common in beef cows compared with dairy. Body condition score again, can increase the risk of uterine prolapse.
Overconditioned cows are more likely to have uterine prolapse. But there are sizeable calf factors as well, so it's been evidence that larger calves and male calves, which obviously are often larger calves themselves, can increase the risk of uterine prolapse. There are other reasons why male calves may also increase the risk of you try prolapse that will come to, but we also must remember.
There are human factors at play as well in terms of risk factors for you try prolapse. So unfortunately, we have clients which Use the calving aid as a carving jack rather than as a carving aid, you know, and they put excessive traction or tension on, then that can increase the risk of a uterine prolapse as well and obviously more generally increase the risk of trauma to the calf or trauma to the cow as well. We should be using loads of carving aids, not as carving jacks, just to yank calves out of cows.
Causation Well, two main factors here, finding uterine prolapses in the adult cow. Dystopia And hypercalcemia. And if we think about the fact that we know our large calves or our male calves may increase the risk of bo uterine prolapse, well, we know also both of those increase the risk of hypocalcemia as well, so it's not surprising that they also increase the risk of bovine neutron prolapse.
It may be a factor in itself, or it may be that the age is a factor because it's linked with hypercalcemia. We know the odds ratio for clinical and subclinical hypocalcemia increase once cows are greater than or equal to 3 carvings. More rarely it does happen.
We also see mechanical failure, so failure of closure of the cervix, meaning that after carving the uterus sort of follows through, or as I say, that we do unfortunately still sometimes see it is physical force causing the uterine prolapse. But if we consider the hypercalcemia and uterine prolapse. We know that in hypercalcemia we see a reduction in neutron tone and we get weak myometrial contractility.
And in the Risco EA study, it was found that the mean serum calcium in total with uterine prolapse was 1.52 mm per litre, normal obviously 2.2 and subclinical being anything below that 1.8 to 2.0 bracket.
So management of at-risk cows for hypercalcemia isn't just about preventing clinical milk fever cases, it's also about preventing the other periparteran conditions. Such as ketosis, the other metabolic disorders, but it also can reduce the risk of uterine prolapses are coming. And in our small ruminants, we see a very similar link.
In fact, studies have shown the deficit in sheep with uterine prolapse can be as high as 1.0 millimoles per litre of serum calcium concentration. Remember, hypercalcium in sheep tends to occur prepatri and many more risk subclinical lambing.
Particularly those that are being fed on fodder beet tops or ryegrass in the run up to lambing because these are high in oxalate and they bind calcium, so we have to pay a lot of attention to that. Periparur nutritional period, what's being supplemented as if we're increasing the risk of hypercalcemia, we're increasing the risk of many things, one of which is uterine prolapse after lambing. So, a reminder, what are we aiming to achieve?
Well, we might be presented with Something such as we can see in figure B here where there's the cow is standing, but we can see a small amount of the uterus extruding. Through the vulval lips and visible externally. We may see worse standing prolapses this.
Sometimes the whole uterine body is also out in the horns and really then like that first picture I showed you, you could see the uterus almost down at the level of the hocks, or the ones that we all know and love, the ones that we remember are the cows. Down and have uterine prolapse as well. Obviously we know hypercalcemia is related to instances of uterine prolapse, and we know with hypercalcemia are far more likely to be down themselves as well.
So it's not surprising that lots of uterine prolapse cases are recumbent when attended by the vets. So If we think about There's cool coming in. If it's out of hours, they might ring straight through to your phone.
If it's in the day, they might ring direct to your phone or you might have to call by the office and have to call your client back. So. As with anything, It's a good place to start, to advise the farmer, how long you're gonna be so that they can manage expectations and they can get as much ready in advance as they can.
So If the tower is ambulatory, then we want to keep it calm and separated from the group. If we can move it into a crush or move it into a pen and keep it quiet and calm, that's important. The more the cow is moving, the more likely they're going to cause physical trauma to the uterus, particularly if it's a large prolapse.
There's a risk of damage against the legs or feet going through the uterine tissue as well. Or other cows causing trauma to the uterus. If the cow is down, the farmer should leave it down, but they should where possible, separate it from other cows if they can move other cows away, often providing a small bucket of food can help keep the prolapsed cow calm.
Often this can happen quite quickly after calving, to make sure that they are attending to the calf that they have. Treated its navel, that they have provided colostrum because if the cow is down, that calf's not gonna be sucking and getting its colostrum, so it will need supplementation. And again, just make sure that the calf isn't causing any trauma to the prolapsed uterus either.
Near the time, I would tell farmers to prepare 2 buckets of warm water close to my estimated time of arrival. And I also encourage them to get a clean empty feed sack or if they don't have one of those clean silage wrap, if they have some that's not being used yet, or a bed sheet also works well or towels, then again, probably not the favourite towels from the house and not be able to use them again afterwards. And when we arrive on farm.
We want to make sure we gather everything we need at once to reduce unnecessary trips back in from the car. We want to be prepared. So just thinking about equipment, we'll discuss medications later.
Obviously, we need appropriate. PTE, if it's out of ours, we may need a head torch. Hopefully the farmers prepared us our two buckets of warm water.
If not, make sure you get those. We're gonna need lots of obstetrical lubricant. You have your two different sizes of syringe with appropriate sized needles.
We are obviously going to be giving calcium later, so have a flutter valves ready. Hopefully the farmers provided the feed sack or the clean bed sheet. Either way, they must be clean.
We're gonna need a holder. Might have to do a repair, it's always good to prepare a surgical kit, and we may want nylon tape, I'll be a needle and. Our cattle pump and drinks at hand as well.
And then we need to consider initial assessment and restraint. So this is appropriate for your safety, for the farmer's safety, and for the cow's safety just as much as well. And I always use this calendar that I showed you earlier as a good example of this.
What are the major issues here? What can be done to mitigate that risk? So you can clearly see from this picture how agitated and stressed this cow is, you can see.
The sheer size of the prolapse there, but you can also see. There's no crush. We don't have excellent huntings here.
There's no calving gate. This animal is free to swing all the way around through the full 180 degrees. There's no.
Protection there and if the cows to go down, we've got to think about the kind of knot that's on that halter as well and the risk of sort of strangulation or asphyxiation as well. So this is by far a non ideal setup where possible. We want to be hoeing the cow in a crush or in a calving gate or a knocking hedge yoke where restraint is better.
Obviously, We have a wide variety of farms and a wide variety of handling systems in the UK and in other countries across the world as well. So Major risks are obviously animals, human health and safety. We've got the prolapse.
This cow may be at risk of going into sock. If that animal is thrashing around as we would expect from looking at this picture, then there's greater risk of trauma to the prolapse. We can't see in this picture where the calf is, is the calf wandering around and likely to get knocked by the cow or to cause trauma to the prolapse?
We've got to consider both of these things now. So to mitigate the risk, well, we've discussed physical restraint. Obviously chemical restraint with sedation is possible because this happens after carving.
Obviously there's no risk to the calf, and there's no risk of causing abortions either or introducing partition by giving anal to. And other things you can do, you could place the calf on just on the other side of that gate with a person to the calf at the head, so the car can see the calf and that will obviously help calm them down as well. So as I say, if the towel is ambulatory and we can get it into a crust, then this is obviously an ideal working environment, and we can always protect the uterus that's prolapsed by wrapping it in damp towels, etc.
While we move that towel from the pen to the crush, and we want to do it as calmly as possible. So if there is the calf, bring the calf with it, particularly if it is a suckler. And if it's a big predator, you may need to help elevate it or you move the couch crush.
But if the cow is down, it's fine to keep the cow down. We can reposition the cow, move those legs round into what we colloquially call the frog leg or the spatchcock chicken position as we can see here in this picture. Now, if the cow is Laterally recumbent, obviously we've got to roll the car into external and bring those legs round.
It takes sizable force, so make sure that you do. Get assistance from the farmer, other people on the farm if you can, and You know, we can also use ratchet straps to help create momentum as well to Bring the legs round to where they need to be. By having the animal in this frog legged position, I've seen in this picture, obviously we're in a stable sternal, but also having the legs like that opens up the pelvis, creating that 30 degree angle in the pelvis, which means that once we elevate the prolapse and it starts moving, and we start replacing the prolapse and we get the benefit of gravity to help the uterus fall into its natural position within the abdomen.
At this point, it's vitally important to test if your patient is in shock. They might be in shock because of internal bleeding, they might have had organ prolapse, sometimes these prolapses can include other organs or they may have had visceral entrapment during the prolapse as well. And most likely you're gonna be in a hypovolemic shock.
So we need to assess the signs of shock and make a very quick, very important decision whether we need to treat shock if it's present. So key factors for assessing signs of hypovolemic shock, you know, we're likely to see recession of the globe, hypothermia, they're more likely to be laterally recumbent, increased eyelid skin content, and cold and dry or mucosa as well. If the patient is in shock.
I would strongly recommend that you discuss the prognosis with the pharmacy. Uri prolapse cases presenting in hypovolemic clock on a much lower. Survival rate.
So it's something that we need to discuss carefully with the farmer, and if we are going to intervene, we need to intervene quickly. We need to correct the hypovolemia and the hypovolemic shock before we replace the prolapse. But if there is an internal bleed and a significant one causing the hypoemic shock, we may not know that and that's why the discussion of the prognosis with the pharma carefully is so important.
If we are going to treat hyperlimic shock, then we want to give 3 litres of hypertonic saline 7.2%. We want to give that intravenously.
And then we want to rapidly follow that with 20 to 25 litres of all warm water for rapid volume expansion and correction. And this is the place where often people say, well, should we put electrolytes in the water that we pump after giving hypertonic saline? And the answer is no.
For the best rapid uptake of that oral water that you're pumping into the rimen, we want to give plain or water because then it's uptaken by the osmotic gradient that we set up by putting the hypertonic into the circulatory system. And if there is shock, once we've corrected it, or if there isn't shock once we've positioned the car appropriately, we need to consider our pre-procedural medications. And so We're going to need to give an epidural.
And What you'll hear vets and practitioners discussed is whether or not they want to spike an epidural, so to add xyzine alongside that procaine hydrochloride, it's optional, but it prolongs the duration, and if we don't give an appropriate epidural, then obviously we'll still be trying to replace the uterus against contractions and the straining, so we need to provide the epidural. We're not spiking the prolapse or if we need chemical sedation, chemical restraint, and obviously we can give IV Xylazine 2%. At that do there, we get no standing sedation if handling necessitates, but if we're giving intravenous thylagine.
Or chemical restraint, then avoid giving extra thylazine in your epidural. For many of the products in the market that are 2% or 20 MB per mL, then If we A the cow earlier then estimated. To give 14, so 0.7 mil of a 20 mg per mL solution to achieve a nice standing station.
As mentioned before replacement, if there is shock, we need to provide those fluids to correct the hypovolemic shock. So 3 litres of hypertonic saline IV and 20 to 25 litres of oral warm water. And then it comes to replacing the pileups itself, getting it back in.
There are a number of steps to consider here. And a logical approach as to how we can approach this. Firstly, we need to keep it clean, so we told the farmer to get us 2 buckets of warm water.
One of these is for washing off the prolapse uterus, whether it is being down and on the floor and it's covered in straw and potentially other environmental contaminants or whether the tower is standing and it's been exposed to. Potential faecal matter or other environments, whether it's been lit by the carpet we need to clean it off with warm water, and if it's on the floor, you can see here, we want to get sheets underneath as quickly as possible. To keep it off the floor and keep it clean.
Hopefully we've had a good epidural and that tail has gone floppy, so we need somebody to either hold the tail to the side or we can tie it to the side with a loose bit of string, you could tie it to the leg, etc. To keep it out of the way. And then we want to do a good assessment of the quality of the uterus, assess for any full thickness tears.
If there are full thickness tears, we need to repair those that's required. Any bleeding vessels need clamping and ligating. And if there is loose placenta, then we can gently pull that away, but only if it's loose to gently tease it, if it doesn't come away easily, leave it in place.
If we pull it off too with too much force, then we're gonna cause trauma, increase the risk of haemorrhage and increase the risk of fatalities. And then when we're happy that there are no full sickness tears, that there's no bleeding, and that we've cleaned the uterus as best we can, then we need to elevate the uterus to aid our replacement. If the cow is standing, then this is where your bedsheet or clean feedback comes into play, and you can have two assistants, one on either side, lifting that feedsack, and therefore they take the bulk of the weight of the uterus and elevate it to the level of the vulval lips.
If the cow is down, then when you've got the cow in that frog leg position, you want to Kneel behind the couch as close as possible and really elevate that uterus body and pretty much take it in your lap so that you've got it as close to the vulgar lips as possible so that we're not then replacing up. And forwards, it's already starting from the right height and we're just replacing it forwards. But before we actually do any replacement, We need ample steal lubricant.
The more lubricant, the easier. And then with gentle pressure, and it's important to use a closed fist, the longer the uterus has been exposed, the more liable it will be. So we don't want to use an open fist or open fingers as we're more likely to cause trauma or tear through.
So with our closed fist. Just gently start kneading between 10 o'clock and 2 o'clock and then work your way round as we start replacing the uterus and, It comes to a point where often it feels like not much is happening and then all of a sudden it starts going all at once and once it starts going back into place, it's really important that you don't stop because then gravity may bring it backwards. You need to keep going, get full momentum, and then that gravity takes effect and brings the utine body down into the abdomen.
And then you'll see in this picture, we want to ensure fuller version of uterine horns as well, so. With more lube, obviously then you can increase your full arm finally and we want to almost do a windmill motion to aid the fuller version of uterine horns. If you've got those lubricant bottles that have the stalk in in the bottle that can help create kind of that propaner motion to aid the aversion of the horns or I say to people.
Use like a 1 litre plastic bottle, like a tonic water bottle. I'm not a fan of using glass wine bottles inside cows. I know it's It's a traditional approach to making sure the horns are vert, but they can smash inside.
They can cause more trauma as well. So it's not recommended a plastic bottle with a full of water with the lid on will still get the same emotion or even empty will get the same emotion. And if you've got long arms, you may not need any bottle at all.
Historically, people may have pumped large volumes of fluid or even pumped iodine. In to try and aid a version and again neither of those are recommended anymore. But sometimes you can't replace the uterus.
It's very difficult and if that's the case, you can. Elevate the hind ends of the tower with a with a with a lift so you could put your bags or hoist on and get the car elevated so that the Hind legs are higher than the forelegs. If the cows down, obviously it's quite easy to you don't have to lift them very far, and then gravity just kind of aids with the replacement.
But if you are going to lift the cow just elevate the hind limbs, you need to get that uterus in really within 10 to 15 minutes of lifting the cow maximum. So prepare everything in advance if that's the approach you're going to take. And so Once the uterus has been replaced and we're confident the horns are fully inverted, then there's debate as to whether or not we stitch or don't stitch.
Now abuasua. It won't stop a full reprolapse if that car is determined, but what it will do is it will buy time and it will reduce the risk of the partial prolapse as well. In Norway, 98 respondents use, it's a bit more variable in the UK, but there is definitely still a far more expectation.
But if you are going to stitch, absolutely do a boon the stitch and use the nylon tape and it spreads the pressure. So if there is any straining it spreads the pressure, please don't stick with like a nylon suture or a PDF or something like that, because if it is going to reprolapse, that will just teasewire through what reprolapse is, whereas the rua suture is more like a purse string, so it's a, you know, it will spread and obviously. The tape goes in the mucosa, so again there's no risk to any tissue if it does reprolapse.
And if you place one, make sure that you're tired of that you or the farmer or your assistant places the hand vaginally. 2 or 3 fingers to ensure that you're not tying it so tight that you're preventing urination and gonna cause urine scoring. Ideally keep your boona needle really nice and sharp and clean, get it sharpened as much as possible, but if you can't, you can make a small nick in the skin with a scalpel because we're under an epidural, we can do this, and then that will aid the passage of the boona needle.
Remember, the needle stays in the mucosa. We can only do this under an epidural. So after we've replaced it, and we may or may not have place to be in the future.
We have to consider appropriate post-procedural medications. And unsurprisingly, the first one is analgesia, so non-steroidal anti-inflammatory, meloxicam, or we could consider ketorofen because of the nil milk withhold, but we are gonna need antibiotics. And more visa and beef cows that's probably less important.
Oxytocin 10 to 40 international units after a replacement to aid uterine involution, and if we have left any placenta behind because it wasn't ready to come away, then the oxytocin will aid that as well. These are contaminated dirty procedures. There, there is no debate about that.
The utine body is exposed to the environment if they are down, and obviously there's even more exposure and there is often potential faecal contamination as well, so. Antibiotic cover is entirely appropriate, but what's appropriate is a broad spectrum of category D antibiotic. There's no indication to give a category C or higher class of antibiotic.
We only have 3 to 4 days of antimicrobial cover. So that could be a long-acting penicillin D, it could be an amoxicillin, for instance. And remember, many of these are linked to hypercalcemia.
Therefore, we want to give Intravenous calcium on our flatter valve. But remember, the intravenous calcium has a very short because of a rapid but short-lived effect, and then if we're not careful, we get this nadir, this rebound hypocalcemia, because we're providing exogenous calcium in a large amount and we're not encouraging the mobilisation of normal calcium channels. So we want to follow intravenous calcium with all calcium and all calcium propionate has been shown to be efficacious.
Dissolved in water, 500 grammes will. Elevate the blood calcium concentration for at least 12 hours and prevent that rebound hypercalcemia from the IV. So give the IV for the rapid and the oral for the prolonged and sustained.
If we're doing this in an all drench, then we're also gonna correct the dehydration that's seen as a result of the uterine prolapse as well. Farmers always came to know what the prognosis is. So if we both successfully and quickly, then the prognosis is favourable.
It's been demonstrated in the literature that survival is lower where it takes more than 20 minutes to replace. There's a 3 times greater risk of death if it takes more than 20 minutes to replace, and that is actually why you're physically replacing it because obviously you're likely to cause more trauma, more damage, etc. And more edoema to the uterus potentially.
So prepare and plan before and then start replacing and replace quickly. There is risk of rupture of the uterine artery either when the cow prolapses the first time or during the replacement. And significant uterine edoema or preexisting trauma from when the cow has prolapsed or when it's being replaced, reduce the survival rate.
But the good news for farmers is less than 1.5% repeat in subsequent lactations, so. There is no need to.
Always cold towels that have a uterine prolapse after calving because the odds of repeating are very low. And actually if we look at the literature, various studies over the last 35 years we can see survival rates between 64 and 82% and actually more of them are on the higher end of that range than the lower end and all of those five studies assessed also conception rate and subsequent lactations and good news for farmers again, if we follow an appropriate voluntary wait period, then conception rates above 80% in the next lactation. So if it goes in well.
The prognosis is good. But actually what I would say, As if we have herds with a higher than usual or a sudden cluster of uterine prolapses, it warrants further investigation. It probably warrants a calcium screen looking for dyscalcemia and other transition cow problems as we know.
Obviously the risk factors. For the prolapse would warrant further investigations. And then If we turn our attention to shape.
Well, They have a low incidence rate as well, 0.1% reported in the literature, and Probably far fewer of these receive ve the attention, often these are culled by the farmer on farm because historically it's been cost prohibitive. Now at the time of recording in the UK, the price of lamb and the price of sheep, even collies, is Almost at a record all-time high, and therefore we probably are seeing more of these this season than in previous years because the return on investment for the farmer is greater compared with coming out on farm.
So practical tips for replacing the over neutron prolaps, obviously. These are a lot smaller than cattle, so it's a lot easier to invert the U and elevate those hind legs to rapidly replace it. Historically and a bit of a bit of a farmer's wife thing, people have used sugar to coat the uterus as a theory that it would draw out the edoema.
If you use an appropriate epidural, appropriate lubricant, and a good technique, you won't need this, adding a lot of sugar into the uterus, then this creates. Seeded or a soup really for bacteria to grow increases the risk of endometritis and infections that they may, may well kill thee anyway. So please do not do it.
It's a good technique and an epidural instead. We can get a mini boona needle or we can use a postmortem straight needle to still place the buona suture and also you get that 3 millimetre nylon tape compared with the 6 millimetre that we use in cattle. But the risk of trauma is greater.
The uterus may well be a bit more viable, so more care needed during replacement, but also when the prolapse itself happens often. Just because of the way lambing works, there are more ewes around, there are probably more lambs around as well, there's a greater risk of trauma before these are picked up by the farmer, particularly in large flocks as well. So meditations.
We still want to give our epidural, obviously it's a lower dose and remember not all local anaesthetics are licenced for sheep to check if you need to give off licence withdrawal period advice, but we can spike these. Absolutely, please give meloxicam at 1 MB per kg. That is the licence dose for meloxicam in small ruminants in countries where it is licenced for its use.
So while it's not licenced in the UK, this dose is licenced. In sheep in other countries and as the do we should be using off licence. Oxytocin has been demonstrated to be efficacious after replacement, and again, we still want to be giving an amoxicillin.
Or other broad spectrum category D, no justification for category C or combined penicillins and streptomycins. We still want to give calcium, but obviously at a lower dose. So 1.5 to 2 grammes of or calcium, which would be equivalent to 15 mLs of a product that contains 50 grammes of elemental calcium in 500 mL.
And actually exactly the same reason as for the cattle. But lastly, it's important that we just remind ourselves on the ovine epidural. In one study of over caesareans and cysto vaginal deliveries, it was noted that the The number of practitioners placing an ovine epidural for a caesarean or an assisted vaginal delivery was dramatically lower than in comparable studies for cancer caesareans, and the free text comments in this audit that were done, a lot of them showed that actually it was just a lack of confidence rather than people saying that they didn't need one.
So it's always worth reminding ourselves how to do this. The equipment we need is shown here, noting that you probably want an 18 gauge 1 inch needle, a 2.5 or 5 mil syringe.
We're giving 1 to 1.5 mL of most procaine hydrochloride products, and 0.1 to 0.25 mL of 2% thylaine product.
We're gonna palpate for the sacred coxic kill joint. Cliff and start prop. I remember This picture here at the bottom, this shows that for cattle where we want that perpendicular 90 degree angle for sheep, it's a much shallower angle, 10 to 20 degrees, and we're going to advance until we feel passage through the ligament and flavium.
You'll almost feel a pop or a loss of pressure. Many of you may be used to or may have been taught the hanging drop technique for epidural in tattle. Now this is unreliable in small remnants.
What is reliable is feeling the pop or the loss of pressure as we pass through the ligament and flavium, and you'll see if you're in the right place, the liquid depresses with ease. If there's any resistance, then you need to redirect and replace your epidural. I need to take 5 to 20 minutes to take effect.
If we just use protein hydrochloride, we're gonna get about 4 hours of analgesia. But if we are spiking this epidural and adding that 0.1 to 0.25 mL of 2% ylazine, then that actually prolongs the duration of the analgesia up to 24 to 36 hours, so a significant increase and something that I would very much encourage practitioners to do.
Again, if you're gonna play Sabrina Sula. Or any part of a stitch, then we must be under an epidural and that makes the meloxicam even more important. So thank you for listening to this talk on the management of Uine products and ruminants.
References and further reading is shown here, but hopefully what this talk has shown you is that there is much more to it than just the physical act of replacement. There are important things to consider if we get a big outbreak of prolapses, investigations we should undertake. Hopefully you understand the risk factors and the likely causes.
And the prognosis to be able to advise your clients better and feel more empowered to approach both the ovine and the bovine neutron products. Further information is available on the QR code as well. Thank you.