So today's webinar is on ovine caesarean sections and thinking beyond just the surgical technique. We'll touch on parts of the surgical approach, but the details of the surgery are really well covered in a number of other webinars and insurgical texts as well. So over the next hour or so, we're gonna focus on your periooperative considerations and things that we, as the surgeons can do to maximise our outcomes.

And by outcomes, predominantly, obviously we're thinking about you and lamb survival rates. So I'll introduce myself, we'll discuss arriving on the farm, we'll go through what the data says about the prognosis for caesarean sections. We'll think about common causes of ovine caesarean sections.

We'll then move on and consider what medications we want to be giving, surgical preparation, including restraint and infection control, and then we'll discuss at the end. Post-operative considerations as well and what we can be doing afterwards to maximise our success rates, and then we'll wrap it up with our conclusions. So I graduated Bristol in 2019.

I worked in mixed practise, and then since 2020, I've been working in farm animal only practise. I finished my set AVP in 2023 in sheep, and in 2021, I set up Midlands Advanced Breeding Services, offering laparoscopic AI and other advanced breeding services to sheep farms across the Midlands. So when we think about arriving on farm.

We need to consider, obviously our PPE. So as with most farm visits, you want your boots. Good quality, waterproof top and trousers.

Personally, I quite often go for a Kiwi kit or other similar brands, particularly for sheep scissors, largely because they do padded knees as well. So if you are going to be kneeling down to do your caesarean sections and you know you're in an area where you're gonna do a lot throughout the spring, it's definitely something to consider for your own comfort and, Safety, a good set of nitro latex gloves, I'd add to that as well, because this will involve obstetric examinations. You're gonna want arm length rectal gloves as well.

Some people might opt for a boiler suit underneath, and then most importantly, if we attempt assisted vaginal delivery and it progresses to a caesarean section, make sure you've either got a fresh set of waterproofs or one of those disposable surgical gowns for when you begin the surgery. What we want to think about as well is some practises have facilities like this one in the picture to see keep at the practise, it's something that we do, so we, we've got a lambing room, but importantly, your own personal PPE is exactly the same, but we need to be considering when we're looking at setting up these rooms, how we're going to ensure appropriate disinfection of, Not just the table, but also the floor and the walls as well. So you can see from this picture, we've got those tiled walls there, so they're very easy to wash down and disinfect, and you've got a good drain in the middle of that floor and a sink there as well.

Obviously this sort of setup has a lot of benefits in the spring, because if people bring sheep down to us, it means that we can see far more sheep in a period of time than we would if we were driving between farms. If we are seeing sheep at the practise, it's all year round, but especially at lambing time, we need to really, really consider the zoonotic risk, so thinking about how we're going to dispose of any biological material, and also any PPE that's been in contact with. Any kind of vaginal discharge or these kind of fluids, particularly if you've got non-clinical staff around at the practise, so if you've got receptionists or external cleaners and people who come in, they might not know of the genetic risks associated with the cases that we might see over kind of the traditional lambing period.

So being able to disinfect yourself after you've done the procedure is really, really important. As with everything, we're gonna make sure that we're taking some history questions, normally. You can do this on the phone on the way to the visit, or you can do this when you arrive and you're chatting to the client and and getting set up, so.

I'd like to know if you use lambed before. I'd like to know how old it is and the breed of ram as well. We know Asian breed can give us an indication as to the likelihood of foetal maternal oversize.

We also know that. Different breeds are more. Pray to things like ringwing as well.

I then like to think about how long stage 2 labor's been observed. We know that we want a maximum of 1 hour from the of the first water bag to the lamb being delivered, and the second bag should be intact until right before delivery. I also like to know whether anyone on the farm has attempted assisted vaginal delivery before, because I also know that the more people who have attempted to assist and the longer it's been since the start of stage two labour, the worse the prognosis is gonna be.

And if people haven't attempted to assist, it's always good to know why not. There might be some clear predisposing factors here. If the answer's yes to question 4 and the client or somebody else on the farm has put their hand in and attempted to lamb it, then why do they think a seed is required?

It can really help you consider your lamb survival prognosis rates and also what kind of equipment or what you might be dealing with before you turn up. I'd like to know how many years the lamb was scanned for. This isn't 100%, so I always check even if I've delivered 2 and it was scanned for 2, I will always check there isn't a third in there, that's really important to do because it's not always 100% correct what they're scanned for.

And I also like to know if they've had a caesarean section before, as this can be an indicator as to if I'm likely to face any adhesions or any scar tissue when I go in abdominally. If we think about what the latest literature says in terms of survival rates. For you looking at 7 days post procedural survival.

There's a 2021 study by by Hawkins, which saw 89.2% youth survival rate after caesarean section. And then in the clinical audit across a number of practises in the UK and Ireland that I was involved in in 2022, we saw 94.8% youth survival at seven days.

We then consider what might make this prognosis less favourable. So, in their 2021 study, Boyetta found that concurrent disease, so things such as OPT, significant uterine damage, other notable comorbidities could reduce the rate to as low as 68.5% survival at seven days.

But the picture isn't totally clear when we think about if it's a dead or an emphysematous foetus. So in 2021's paper, they found that this had no impact on you mortality, but in Scott's 1989 paper, he found that the prognosis and the seven day survival rate decreased to 57% if there was a dead or an emphysematous foetus and a caesarean section was opted for. When we think about these dead or emphysemas as foetus cases though, we do have to consider.

Perhaps more of these end up being put through a caesarean section perhaps than in cattle, as sometimes it's not as logistically possible to do er a full photostomy in in in a ewe compared to a in an adult cat. So a lot of the time we know dead numbersy foetuses may affect survival rates in in cows and quite often we can opt for a full section phototomy or something like that, but that we might be more limited as to what we can do in use. So it is interesting that the data varies as to the impact on survival rates at 7 days for the uses.

When we think about lambs. We wanted to look up. How many that were delivered alive were still alive for 7 days.

So in our, in our study, we had 78.1% of lambs delivered alive from caesarean sections still being alive seven days later. And then when we look at at the total number of possible lambs, so anything presented in utero, how many of these were alive at 7 days.

You're looking somewhere between 62 and 74, 75% survival rate. It is worth noting that our audit study in 2022, we saw 209 surgical cases of which we saw 107 caesarean sections, and in Hawkins's 2021 paper, they looked at 205 caesarean sections over a greater number of years. When we then look at the evidence around common causes of caesarean section in sleep.

Unsurprisingly, foetal and maternal disproportion accounts for a high amount here. We see 27.2% across three recent studies into causes of ovar and caesarean section, more commonly feature to maternal disproportion being reported in you scanned as carrying singles and some ram breeds.

Elevated this as well, so particularly Bell taxes, in some of the studies and maybe some of the textual crosses. Interestingly though, in, The 2022 study that I was involved in, we found that clearings were not actually overrepresented as needing caesarean sections, which is commonly what farmers report, as they say, oh, I'm lambing a lot of sing clearings this year. I think we're gonna need a, need a lot of involvement.

Actually, we found 2 year olds were the most presented uses for caesarean section. We then moved on to consider uterine torsion, so across these three papers out of a possible 621. We saw 17.7% reporting with the uterine torsion.

This is quite interesting when we look at the literature, a lot of people say perhaps this is underreported in sleep. The degree of torsion varies a lot more than in cattle, but we also know that there's not as much literature published, so we can't make a broad statement on. The more likely rotation of direction, or also, we also know that unlike cattle, it's very hard to rectal and be able to work out the degree of torsion, so perhaps more of these go for a caesarean section rather than are manually corrected.

Again, probably not that surprising. Incomplete cervical dilation accounts for a large amount of cases. So across these three papers, 37.8% required caesarean section due to incomplete cervical dilation.

Commonly for ICD we're seeing maybe 34 millimetre opening of the cervix. When we look further at common causes of assisted vaginal delivery, male presentations, . Multiple lambs kind of tangled up within the uterus.

Common causes have persisted. Vaginal delivery and veinary involvement, but we found they were not in the top three causes of surgical caesarean section. So, When we look at incomplete cervical dilation, we saw that across these three recent studies, almost 40% of caesarean sections were due to this, so it's not actually anything we can do.

Relatively new entrant to the market being licenced in 2017 is Denoviine hydrochloride. So in the data sheet and the SPCs for this product, it's licenced to relax the soft tissues of and provide analgesia to the soft tissues of the birth canal. For example, relaxation of the cervix and dairy heifers.

We use it in our practise to variable success in cattle, and after a number of conversations with the manufacturer who claimed it has benefit in cases of ICD or ringworming use, we've started using it since 2021 to mixed effect. The manufacturers claim peak effect happens 15 to 20 minutes after injection. And so perhaps this is a product that we should be selling to clients, as it's something that clients can administer, assess the effect of, and then if they still aren't correcting the ICD then obviously they know it's going to be a veterinary caesarean section, which means that when we turn up, we almost know straight what we're dealing for, and this may also impact and improve outcomes.

So if you do want to administer Denaine hydrochloride to use. The currently only licenced product is Senslax in a 140 mg per mil solution. This remains off licencing sheep, so you will need to apply a 28 day meat withhold and a 7 day milk withhold.

The manufacturers claim for a 50 to 70 kilogramme ewe, you want to give a dose of 3 mil into the muscle, and for a bigger at 70 to 100, you want to be giving 5 mL. Again, we see peak effect at 15 to 20 minutes post injection, but the manufacturers advised you can give another dose if required. We then move on and we need to think about preoperative medications.

What analgesia are we gonna be reaching for? Overwhelmingly, there's only one answer to do we need to be giving perio-operative analgesia? Absolutely we do, and that's gonna be in the form of non-steroidals.

Pre-operative administration is recommended, and we tend to recommend this is followed by a postoperative course for a minimum of 3 days, but please remember, we still have no licenced non-steroidals for sheep in the UK so we are giving this under the cascade. And we really need to make sure as well that we're considering how we're gaining or recording the off licence consent for giving these products. Whether we're writing it on clinical notes, whether people have forms, we need to make sure that we are recording it and we know that we've got the consent to use this product, and that the clients are aware that it is off licence as well.

So make sure that when you're writing your labels, you're not just putting an auto generated one on that's gonna auto populate with the data sheet off licence information because that won't be correct for using it in sheep. So. Main options, meloxicam or ketoprofen.

What's really important to note is that in the southern hemisphere, where meloxicam is licenced for sheep, so in Australia and in New Zealand, the day dose is 1 mg per kg subcut. So this is different to what we have licenced for cattle, and therefore, this is the dose that I would strongly recommend that we're using in sheep over here. So 1 mg per gig subcut is equivalent to 1 mL per 20 kg, and that's what we should be using in keep.

Remembering our 28 days off licence. If you're gonna reach for a ketorofen or flunexin kind of product. We'd be reeking for the same dosages as we would be for cattle, so for ketorofen, that's 1 mL per 33 kgs, 3 mg per kg IV or IM remembering it still remains off licence and we need to give a 28 day meat withdrawal and a 7 day for milk.

We then want to move on and consider antibiotics. At best A caesarean section in the EU, particularly on farm, is at best clean contaminated surgery. So it's reasonable, therefore, to give you antibiotics using the as little as possible, but as much as necessary mantra.

We need to consider what kind of pathogens we're likely to encounter and what we're going to want to be. Prescribing our antibiotics for, so we know commonly we're mostly gonna be seeing mixed coliforms. So, in terms of what might work very well, so amoxicillins, penicillins, amoxicillins, and clavulanic acids, we know these are gonna work, but we therefore can think back a level and when we looked at what people were giving in our 2022 study.

98.1% of caesarean section patients received antibiotics. The 1.9% that didn't, when we actually delved into the data, these were all salvaged caesareans where caesarean section was performed, and then the EU was euthanized for welfare grounds on the farm, justifying not giving antibiotics.

We still saw 8% of respondents administering intraabdominal or intrauterine antibiotics. We saw no positive impact on survival rates, outcomes, post-op infections or anything to justify the use of this. And as we know, if we're giving systemic, we don't need to be giving intraabdominal or intrauterine antibiotics.

So we'd really strongly advocate not to do this. Interestingly as well, when we consider the EMA categorizations and sort of prioritising the antibiotics that we're reaching for. 81.3% were selecting for category C antibiotics.

In a seminar conversation, when we looked further into this data and we spoke to a number of respondents, we, we delved into this more and asked why people were reaching for category C's. And almost overwhelmingly, if people were reaching for category Cs, it was penicillin and dihydroceptomycin, so peninstrep. And we asked people why this is what they used, and a number of common themes came out.

So it's what we've always done. It's what I was taught when I started practise by my then boss. It's already in the surgery kit when I pick it up.

And the farmers buy it by the bottle and therefore have it on the farm. When we're thinking about following rumour guidance, EMA guidelines as well, we need to really be able to justify why we're selecting a Category C over a Category D. And if you're looking at mixed coliforms being your most commonly encountered, and when we look at the data that came out of our 2022 study, we find no evidence in the literature to show any decrease in the survival rate, surgical success, or incidence of postoperative infections.

From using a Category D compared to a category C, so very much, we would be encouraging people select for a category D. I wouldn't say any of those four reasons above justify reaching for a category C before using a Category D. So.

It's very easy to change what bottles you put in your surgery box already. We've got a real opportunity if we're saying that farmers are just coming in and ordering penle by the bottle off the shelf or other amoxicillin clavulanic acid, for instance. It's a chance to engage the farmers when they order and discuss why they're using it.

Is it because historically it's what we as the vets have recommended? Is it because it's cheap? Is it just because that's what they've always done?

There's a real opportunity to engage with them and talk to the clients about responsible antimicrobial use as well. And now we've got things like the animal health and welfare pathway, funding vet visits to do flock health planning. We can really engage with people and talk to them about why we're recommending moving to category D's.

We also know price wise, most of the amoxicillin products, even the long acting ones, when you actually compare the amount of milks you use and how often you're giving it. A straight amoxicillin or a straight penicillin product works out just as competitive price wise as going for a penicillin dihydrostreptomycin product and quite often cheaper than an amoxicillin clavulanic acid product. So when we continue to think about antibiotics.

Knowing that there is no evidence of any negative outcomes from using a Category D at a higher level than a Category C product. Consideration should be given to antibiotic use. For everyone caesarean sections by looking at the group of product.

EMA category should be an influencing factor, and we should select these Category D prudence products before Category C caution products. So category D products, amoxicillin, penicillin. Of which a number of brands and different trade names exist with licences for sheep.

There's also real opportunities, as we say, client communication to change attitudes, and within practises we can engage with things like the Farm vet Champion scheme and also setting smart goals around reducing our category C use over lambing time. By selecting for category Ds for assisted vaginal delivery cases and ovine caesarean sections. The next perioperative medication to consider is the use of the epidural.

Epidurals can be highly beneficial in sheep, and they could, in my opinion, be utilised more by practitioners. We know it's now commonly used and commonly taught as standard as part of your preparation for a bovine caesarean section, but it might not be done as commonly for ovi caesarean sections. We also find.

When we did our studies and we went out and we also spoke to other practitioners beyond the scope of the study as well, most of the people using it perhaps are administering it to assist in vaginal delivery, rather than giving it as part of their, A caesarean section preparations. So We went further and we thought about why are people not commonly doing. I know vines take rosal epidural when we know that it's epidurals are commonly used for preparation for bovine caesarean section.

Common trends came out, some people felt they were lacking familiarity with the technique. Some people felt that they manually didn't need it because they could manually deal with the contractions when they were doing the caesarean section, and they could retain any abdominal viscera that was coming out due to the contractions. We also need to make sure if we are selecting for an epidural that we consider the pros and the cons.

So, in the literature, the largely reported negatives of giving a sacred coal epidural on a caesarean section patient is the risk of the short term ataxia, which may have an impact on the lambs and their ability to suckle and gain access to that colostrum. But the pros. Can reduce the length of time that the surgery takes, it can improve the sterility and decrease the risk of any exteriorization of any abdominal visa.

If we're going to perform a crooks the epidural, then the equipment we need is highlighted here with within the box. So from reviewing the evidence in the literature, we are, we are recommending 1 to 1.5 mL of procaine hydrochloride and there is the option obviously to spike it with 0.1 to 0.25 mLs of 2% xylazine.

If we are spiking it, then we really need to pay attention to ensure that the lambs are getting access to the colossum and consider supplementation if we are worried, where a spiked epidural can give 24 to 36 hours of anaesthesia, whereas a plain procaine hydrochloride, only one, is reported to give just 4 hours of epidural anaesthesia. So how do you administer the sacred royal epidural in a sheep? What we're gonna want to do is we're gonna palpate for the sake of coccygeal joint, which when we're flexing the tail dorsoventrally, it becomes the first movable space as the S5 coccygeal 1 joint, as indicated here.

By the pictures We would be going for space B, most likely. In cattle, it's interesting, a lot of people might opt for space A as the, the first coxadeal space. This is because in older cows, it's reported that the sacred coxadal space may ossify, whereas this isn't widely reported in the small ruminants, and so we have large success in location B.

We will clip and prep over the site where we're going to go, so. Using something like a sterile surgical spirit, for instance, just to prep the site. What is important to note though is unlike in this picture, where we're going in perpendicular to 90 degrees like we would in a cow, we want to be going in at a much shallower angle.

You want to be considering 10 to 20 degrees. We then want to advance the needle until you feel a loss of pressure or some people report it feels a little pop as you pass through the ligament and flavium. This is where in a cow, you might then do your hanging drop technique, but it's worth noting that it's not reliable in small ruminants.

And if you felt the loss of pressure or the pop from going through the ligament and flavium, you should be able to depress the liquid within the syringe with ease. If you get any level of resistance, we know that we need to redirect and we're not properly in the space. This should take 5 to 20 minutes to have effect.

Other perioperative medications to consider would be the use of oxytocin. Post-operatively, oxytocin can have benefits such as increasing the speed of uterine involution, reducing the risk of retained foetal membranes, and it can also increase milk letdown. There's some debate amongst practitioners about the success rates in sheep compared to the success rates in cattle.

So in our 2022 study, we recorded widespread success in ewes that underwent ov caesarean section or ewes that underwent assisted vaginal delivery as reduced post-op complications and, as I say, in the study. And at my own practise, we have very good success helping use release milk by giving dosages of oxytocin. If you are going to administer clambuterrol to aid uterine relaxation for assisted vaginal delivery, such as for manipulating limbs or malpresentations, then it is recommended that you give oxytocin to encourage and increase uterine involution afterwards and almost counteract the actions of the clambuterol post delivery.

What's important to note is that whilst there are licenced oxytocin products for sheep on the UK market, the dosages differ by brand, and this is something to be really careful of. So, as you can see here, if we're using oxytocin S, it's 2 to 10 international units per year in the muscle. Which is 0.2 to 1 mL per U, but if we're going for an oxyobebell, they're recommending a dose of 10 to 20 international units per U, under the skin or in the muscle, which is a bigger dose at 1 to 2 mLs per U.

So just be aware of where we're sitting within, Within the licence considerations and any off licence withdrawal periods that we need to apply if we're using different products and not changing the dosage. Personally, I tend to go for about 0.4, 0.5 mLs per year of the oxytocin S as that's the product that we're stock.

And as I say, in our practise we've had very good success with this. When we then come to consider beginning the caesarean section, we need to go to our car, which on a good day might look as tidy as this, and we need to consider the equipment that we're gonna need to perform our surgeries so that we have everything, and once we're sterile, we know we've got everything and we can just crack on with the surgery. So in an ideal world, I like to put all my equipment into a handy toolbox or.

A something like an Orban in tube box that's weatherproof, waterproof, easily disinfectable and has the bonus of having a lid. To keep it clean. So, a lot of this might happen out of hours, so having a head torch is always good.

As I mentioned at the start, we're gonna make sure that we've got a clean parlour top or a new surgical gown for when we begin the surgery. I like to take my own buckets and I like to have 21 for prepping myself for surgery and one for prepping the patient. Local anaesthetic and applicator, that's something I'm gonna discuss in a bit.

Obviously needle syringes, we've talked about non-steroidals, talked about, obviously we're gonna be selecting for a category D antibiotic. Materials for scrubbing, you've got options there in terms of. Things like an pobbione iodine or an alcohol based hand rub, surgical gloves, surgical kit, lathes.

Make sure that you've got absorbable and non-absorbable sutures, make sure that you've got at least one round bodied sterile needle for closing the uterus. Oxytocin, if you want to use it. This is a chance to consider grabbing something in terms of land revival, but we will come on to this later on in this webinar.

And as I say, I'm a big fan of foam padded knee pads. So either in your waterproofs have padded waterproofs, or you can get those ones that builders and tradesmen use very cheaply out of B&Q, but I find by the time I've done a lot of caesarean sections at the end of a lambing season, I really appreciate that I've been wearing these. And then like to think about the options for surgical restraint.

So, tables, absolutely a very good option. Probably more likely if you're doing a caesarean section at your own practise, but they absolutely are possible on farm. So as you can see here, this top picture is a caesarean section patient on farm on the table, and this is some of our set up in our lambing room or our small animals small ruin and procedures room at the practise where we've got a table.

In an ideal world, I wouldn't need to be kneeling down like that to perform surgery at the practise. Height adjustable tables or tables which you can turn over are very good at protecting your back, and it's something to consider if you are going to invest in a table for procedures at your own practise, do think about something that's height adjustable. And when we're doing this on farm, there are ways of working at height that's good for your back as well by considering how we're setting up.

Commonly on farm, a lot of people are gonna be using bales, they might put a pallet on top of a bale, they might just give you bales. As you can see from this picture, this isn't ideal in an ideal world, what what I'd recommend now is that you get something like a sterile surgical gown and you put this underneath the patient or on top of the bail or the palate just to again decrease your risk of environmental contamination. If we are using pallets, you can obviously restrain the limbs to the table, which you're making from the pallets, which can again reduce movement.

But most commonly, as in this middle picture, the patient is restrained by the client on farm, or in practise, it might be by the client, or if you've got bet techs or nurses who assist, then it might well be by one of those. Most importantly though, pick something that is sturdy, pick something that is the correct height for you to protect your back, and pick something that is clean and that you can disinfect afterwards. We'll then move on to consider once we've got the patient and we've got the table, we'd like to think about local anaesthesia.

So, most commonly in the literature, people are using an inverted L or a line block. But the volume that we're using really, really varies. The benefits of a line block over an inverted out was it was local anaesthetic sparing.

So on average in our study, people were using 10.1 mL less local anaesthetic from a line block compared to an inverted L with an equally good amount of local regal anaesthesia being reported. When we think about volumes, it, it is difficult.

Not many people advise a dosage for sheep on their data sheets and. It's very variable in Calers how much people need, so it is quite hard to extrapolate down. So when we look into the literature, a toxic dose is reported of 5 to 10 mg per gig.

In practise This means for a 40 mg per mL product, which a lot of them commonly are, a 75 kilogramme ewe, we're seeing an upper limit toxic dose there of 18.75 mil. Now that's not a huge amount of local anaesthetic, and in a number of studies and audits we did, we found the amount being used really varied.

Some people were doing sort of. 1012, 15, some people were doing 20, but we were seeing upper end limits of 80, 85 kind of mil as well, and so, There's two options really. Either more work needs to be done in terms of researching a reliable toxic dose, given that the data device is lacking, or a lot of us are getting quite lucky in not seeing.

Commonly adverse side effects, so the CNS toxicity signs. But we might be skating very closely on thin ice, or the other option is that actually a lot of what we're administering isn't going into muscular and it's ending up sort of free within the abdomen if we're going through the muscle and the peritoneum when we're injecting, which is quite commonly a risk because the muscle is obviously very thin. So What we know is The literature reports very well that we can do a 1 to 1 dilution with sterile water for injection or surgical saline, and this can very much increase the volume we use without wildly getting as close to that toxic dose, and a lot of people now are recommending this.

I myself have recently moved to using effectively a vaccine gun that I put my local in, this lets me really control the amount I'm administering in each place and make sure that I'm staying underneath any toxic dosages, so I will. Mix my local anaesthetic with my water for injection and then put that onto the vaccine administration gun, making sure that obviously we've got a clean sterile needle for every new patient. But that way we're very controlled, you know, you can be putting into say 2 mL blebs very accurately at the right concentration and avoiding any toxic dosages.

As with a lot of things in. Not all the procaine, hydrochloride, and adrenaline products on the market, which most people are using for local anaesthetics, are licenced in cheap. So, adrenocaine is not licenced in she currently, but other products such as Procamidor, Giro or proneshesic are licenced for use in sheep.

So make sure again, we're keeping an eye on off licence recommendations, minimum withdrawal periods, and the advice that we're giving. When we're preparing for the surgery, the other important thing we're considering is infection, prevention and control. People might want to do a surgical scrub.

So we might be using a chlorhexine product, or we might be using a pobdone iodine product for both scrubbing the patent in terms of patient prep and also for scrubbing ourselves. One thing that I'm always quite mindful of is what are we doing in terms of buckets when we're preparing for surgery? Are we using farm buckets, are we bringing our own that we know we're clean?

And also, what's happening in terms of water? Is it water provided by the farm, in which case, are we happy that it's mains water and not borehole water, which might carry increased infection risks. And obviously, if we're using farm buckets, how clean are those buckets?

We know when we're talking about things like calf health, for instance, or lamb health, the cleanliness of the buckets that milk and things is fed for is really important, and I think it's just as important if we're using it to prepare patients for surgery. As I say, For preparing ourselves for surgery, we might be using a surgical scrub. Or we might be using an alcohol-based hand rub.

All three of these options. Are very well recommended in the human surgical preparations literature. So AFPP say all of these are recommended in a farm situation, there might be benefits to an alcohol-based hand rub because we're avoiding this bucket and farm water availability thing.

But what we do need to consider if we're using an alcohol-based hand rub, is when you're doing your hand wash beforehand. The most commonly used alcohol based hand rub would be sterilium at the moment, and sterilium. When we talk to their reps, they say that you can't use a chlorhexidine or a providone iodine product for your hand wash before as it may inactivate the alcohol-based hand rub.

They do obviously make their own hand wash, which is Bactylin, but it is something to consider when we're doing that preparation. We also want to be considering sterile surgical gloves. So Surgical gloves reduce the risk of infection to the patient from the surgeon, and they reduce the surgeon's exposure to potential irritants, so this could be abdominal viscera, uterine content.

Interestingly, when we think about what's best practise in human, small animal or even equine abdominal surgery, best practise is very much to use sterile surgical gloves, and in fact, human and orthopaedic colleagues in the veterinary sector are debating whether they're using one or two pairs of gloves. So it might be that we are a bit behind as production animal practitioners where best practise is. And in fact, in our audit, we found 10% of surgeons.

Reported a higher level of skin irritation or problems in the area that would have been covered by sterile surgical gloves if they didn't wear gloves. The other thing to consider is surgical drapes. So we know if we're considering surgical drapes, we must balance them not being overly cumbersome, overly heavily on the patient either, and the.

Benefits that they can provide from increased stability, preventing any contamination of your surgical field, so. I like this picture very much because for me, when I'm talking to people about the risk of contamination of the surgical field, this is the point which I find is where it's most at risk of happening. So once you've removed the lambs from the uterus.

As I'm sure you'll all know, what we find is that body will then tends to sink in, and if you're not careful or if you're unlucky, there's a very big chance of wool contamination of your surgical field. Definitely if you clip patch and if you're not careful of that actually passing into the abdomen as well. So this is where having a drip could be really beneficial.

We also need to think about the environmental aspect though, if we're gonna go out and start using a lot of plastic drapes, how that fits with our sustainability views and environmental awareness as well, so. In the literature and within the profession, there are a lot of things discussed. So some people talk about using sterilised clingfilm, reusable towels, recyclable drapes.

There are a lot of options out there. We're starting to see people offering sort of compostable drapes and these sort of things as well. So it is a balance that we need to consider, but there are a lot of benefits to using something as a form of drape to keep wool out of the wound, straw out of the wound site, and these sort of things as well.

So once the alarms are out and we've closed the patient, I like to think about our postoperative considerations. Lamb revival is a very big one. Commonly we'll find this is delegated to the client, somebody else helping on the farm.

If you've got a vet student with you, it's quite commonly a vet student job as well, because we like to make sure the lamb is going well while we are busy getting a very good seal on the uterus and then closing the abdomen. So. In the literature things to consider nasal stimulation.

And coup parts of the chest to help clear any fluid is good. Massage with towels can help. There are products on the market now, such as we quite like a, a red starch, which is a glucose caffeine paste, which can really help give the lambs a bit of a kick to get going.

Obviously we want to make sure we're not recommending vigorous swinging of the lambs by the back legs or anything like this, which is perhaps commonplace on some farms, and we need to make sure we're not recommending. Obviously, once we've closed the U, while we're there, have a look and check if she's got any good colostrum. In our audit, unfortunately, we found 19.8% of respondents didn't check after a caesarean section or an assisted vaginal delivery if there was sufficient colosttrium on the E.

If they've called us out for veterinary intervention, you know, they're clearly investing the money and it's really important that we are checking and discussing with clients about Colostrum. It's a good chance to just go over again the five queues with clients of Closhlum, but also if we need to, we can provide suitable replacess as well, and I find quite often that's the other thing you want to be checking is. Clients might be giving a replacer or an alternative if they use not got colostrum, but what are they giving?

Is it any good? What are the disease considerations that we need to know? Most importantly, make sure that they're sticking to the 50 mL per kilogramme within 2 hours and 200 mL per kilogramme within 24 hours so that people are getting sufficient.

Post-operative medication, this is my chance to discuss with clients what the course is going to be for antibiotics for non-steroidals, make sure they're happy, make sure they've recorded it. Oral fluids is a very big one as well, so for me. My standard, if there are no complications in the surgery would be a select for store product which can be given at a dose of 60 grammes of product in 3 litres.

If no complications and the use seems happy, I like it because it's palatable, so I don't need to drench and further. Interfere with the EU and interrupt that bond forming with the lamb. But there are options obviously to drench if we need to, if they're not taking in any fluids.

It's interesting. A lot of people don't routinely consider postoperative or even post-assisted vaginal delivery oral fluids for use, but in comparison, nearly all of us are recommending people give a post calving drench or a reviver or a drink, you know, we're making sure there's good water supply. For cows after a carving or a caesarean, so actually there's absolutely no reason we shouldn't be doing this for sheep as well, so I would strongly recommend it.

Again, communication is wildly important here. This is your chance to make sure people are happy with post-op care. They're happy with the medication treatment plan, happy if they need to have the stitches removed, if they need to take them out themselves, when to do it.

It's a really good chance to just review everything you've done and check that the client is happy and knows the plan going forward. Postdoc checks are very important as well. Personally, I like to do a phone call after 1 day and after 3 or 4 days as well.

If it's a big farm, obviously, you might find that you're out on this farm anyway within 3 days, and that's a good chance to check in and check how things are going. But a simple phone call is always really appreciated by the clients, and it's also very easy to do while you're in the car or while you're in the office doing a bit of admin, just to check in, and as I say, it really helps build that farmer client, farmer vet bond as well. The other thing I've started doing, as you can see from this picture, is once I've closed the patient and I'm happy, and just before I go, I'll check the Colostrum, I'll take a photo of the closed surgical site so that I can remember if a client texts me back or rings me in 1 or 3 days' time and says, oh, there's a bit of discharge, I think this bit's swollen, how did it look before?

You've got something to reference back to. Now that more and more people have. You know, camera phones or the ability to just text us over a picture on WhatsApp.

I like to get my clients to send me pictures of my op sites as well. It's a really good way of just monitoring how the wound is healing, whether there's any discharge, all of these sorts of things as well. It's very simple.

It takes all of about 2 seconds. So it's really something I would recommend that we start doing. So in summary.

The literature shows the prognosis for a healthy e undergoing a caesarean section is favourable. And we can say this with confidence as an inference based statement to our clients. We know that incomplete cervical dilation and foetal maternal oversize remain common causes of ovar and caesarean section.

We also know that there might now be a medical management role in treating cases of ICD and we also know that perhaps uterine tins are underrepresented as a cause of obstetrical difficulties in sleep. We've discussed considerations about perioperative medication, so we want to definitely be remembering that meloxicam has a different dosage in sheep compared to cattle. So we want to be using it at 1 mL per 20 kg under the skin.

And we've also discussed the benefits of using oxytocin perioperatively. We've also very much discussed our antibiotic categorization should influence product selection. We've discussed that there is evidence to show that Category D use doesn't negatively influence survival rates.

Consider how this links into farm vet champions and smart goals about reducing our category C antibiotic use. Make sure we're waiting for our amoxicillins, penicillins, and we're putting down and not using as first line penicillin, dihydroptomycin or amoxicillin clavulanic products as they are category C's. We've discussed the dosage and the roles of local anaesthetic and sleep.

So consider, are we at risk of overdosing use? Can we do a 1 to 1 dilution? Can we use applicators to be more controlled and where we're applying it?

We've discussed the benefits of post-operative fluid therapy and how this is something that we need to really be bringing into. Post obstetric care of. Sheep, as it's something that we know we're doing a lot and really well in cattle, I think it's very important that we bring this into the sheep sector and we're actively encouraging clients to do this.

And finally, we've considered if we're doing everything we can for infection control, are we using sterile surgical gloves? Are we making sure that our buckets are appropriately clean? What are we doing in terms of scrub?

As we say, this has very much been an overview of things to consider for the over caesarean section that is grounded in the literature. Thank you very much for listening to today's webinar, considering everything but the surgery of the urine caesarean section.