Dystocia

THE DIFFICULT BIRTH

Each spring is such a glorious time of year. As the cliché goes it is the time of renewal and birth. For us in the miniature horse world it is the much anticipated time of foaling. Around this time last year many of us were plotting on how to produce that perfect foal. The stallion and mare were bred. With great anticipation we have been waiting for more or less eleven months to see the results from our breeding efforts.

The process of birth is a miraculous event. The common indicators of imminent birth raise our level of anticipation. Numerous, soft bowel movements within an hour or two of foaling. Nest building behaviors of pawing the stall bedding starts. Sometimes the mare repeatedly yawns. The frequent pacing in circles and looking at their sides further raises our awareness of what is coming. We are all diligent and make sure to be in attendance. We watch the active labor start when the mare actually lies on her side and begins the forceful contractions. We may even hear the forceful gush of fluid as the mare’s “water” breaks. We next observe the milky colored “bubble” (amniotic sac) appears at the mare’s vulva. followed shortly by the foals front legs then head all encased within the sac. With a few more forceful contractions, the entire foal is delivered. We make sure the amniotic sac is broken away from the foal’s head so it can breath. The vast majority of foalings follow this typical progression. What a breathtaking experience!

But what do we do if the delivery does not proceed in the orderly manner as described above? What are you going to do if your mare begins active labor and one of the following things happens. 1. The mare has been having heavy contractions for 10 minutes and you have not witnessed the water break. 2. The mare has been having contractions and she begins to either roll repeatedly or gets up and down and rolls after about 10 minutes of labor. 3. The bubble presents itself at the mare’s vulva or you notice a foot in the bubble but after a period of additional contractions, there is no progress of the foal to be born.

Sooner or later this dilemma presents itself to everyone who accepts the responsibility of foaling out miniature horses. Chances are that if any of the three scenarios above occur, a DYSTOCIA is taking place. This term simply means difficult birth. Dystocias usually involve a misplacement of one or some of the foals body parts that inhibit it from proceeding through the birth canal. Dystocia can also result due to a foal being too large to pass through the pelvic opening of the mare. If a dystocia occurs, the miracle of birth can turn into a heart wrenching event, having grim consequences for the foal and mare. It is important to have a plan of what to do in case a dystocia occurs.

BE PREPARED

One of the key steps to take in preparation for foaling is to discuss, in advance, with your veterinarian the course of action that would be recommended in case of suspected dystocia.

What actions a person takes in the case of suspected dystocia is probably determined by two major issues. How much time is it going to be between the onset of labor and when assistance arrives? Secondly, how willing are you to take matters into your own hands if the answer to the first question is more than about 20 minutes?

THE ODDS

The reality is, if a foal has not been born within 20 minutes of the onset of labor, the prospects for a live delivery rapidly diminish. If skilled assistance is not going to be available, you essentially have two choices. Standby until the assistance comes. The other alternative is attempt to correct the problem yourself and perhaps save the foal. It is a tough call!

In considering the consequences of attempting to correct a dystocia, one needs to realize that the mare and foal are in a serious situation. We are put into one of those “lesser of the evils” dilemmas. If we try to help, the foal and or mare could become injured or die. If we get the foal out the reproductive soundness of the mare may be compromised. On the other hand. If we wait for a significant period of time for help, all of the same consequences still exist and they can even become more serious due to the passage of time and the increased risk of self-inflicted trauma by the mare as she remains in the throws of labor.

ANATOMY LESSON

The diagram above shows a typical foaling with normal presentation and all of the important structures to recognize. Notice that the foal is essentially contained in two saclike structures. The outer one is the reddish PLACENTA which actually attaches to the inner surface of the mare’s uterus. The second is called the AMNIOTIC SAC. The foal is found within this translucent white sac. The foal floats about in the amniotic fluid. The amniotic sac floats about inside the placenta in allantoic fluid. This is commonly called the bag of waters. Notice that when the foal passes into the birth canal, it pushes through the placental membrane (break her water). This causes the allantoic fluid to gush out of the mare. In most cases, shortly (within a very few minutes) after the gush of water, the BUBBLE appears at the vulva. As shown in the diagram, this is the amniotic sac containing the foal.

Time is Important

From this point on, let’s consider you have had a serious discussion with your veterinarian about dystocias, Educated yourself and have decided to intervene in an attempt to save the foal. The most valuable asset on your side is TIME. The sooner you can determine there is a dystocia and take corrective action, the greater chance for a successful delivery of a live foal and preservation of a healthy mare.

There are two important time landmarks that need to be recorded. The first is the time the mare started into active labor contractions. The second is the time that the mare’s water breaks. Usually a mare’s water will break within 5 MINUTES of her lying down and beginning to push. Usually the bubble will appear at the vulva within 5 MINUTES of the water breaking. If either of these time periods pass or the mare begins repeated rolling it is definitely time to call the veterinarian. If word comes back that assistance will not be available for more than 15 minutes, it may be time to intervene yourself if you want any hope of having a live foal.

When did the contractions start?

The first 5 minute landmark is important because if the mare is in strong labor, having constant and active contractions, the water should break if there is a normal foal presentation. The only reason that the water wouldn’t break is if “something” is blocking the exit from the uterus so the water can’t get out.

When did the “water” break?

The second 5 minute landmark is important for two reasons. The bubble should be visible at the vulva within this time frame after the water breaks. Secondly, if the bubble is present there should be observable forward progress of the foal out of the mare. If the bubble does not appear or the foal does not make progress toward birth, something is keeping it from progressing through the birth canal.

Examining the mare

At this point it becomes necessary to enter the mare’s vagina to determine the position of the foal. Keep in mind that this is an INVASIVE process. There are risks involved. Dirt and bacteria may be introduced into the mare’s reproductive tract. Care must be taken to avoid needless trauma to the mare. Once again, it is the lesser of the evils. Lose the foal and possibly the mare or perhaps deal with an infection. To minimize these risks, scrubbing down the mare’s hindquarters with soap and water is important. It is important to thoroughly wash hands prior to entering the mare (preferrably with iodine or clorhexadine( surgical scrub). Also it is important to consider the possible damage that long fingernails and jewelry could do to sensitive membranes of a mare. Those who are prepared for foaling season, keep their fingernails clipped as short as possible and leave their jewelry off until all the foals are on the ground.

Lubricate, Lubricate, Lubricate !

Some foaling attendants choose to use latex gloves or plastic sleeves. Others prefer to enter the mare without gloves after scrubbing thoroughly. In any case, liberal use of lubrication is very important. K-Y Jelly or Non-Spermicidal Lubricating Gel liberally applied to the hand and arm entering the mare is a must.

Generally mares are easy to enter. Their whole reproductive tract has loosened in preparation for the birth. The birth canal (vagina) is about 6 inches long in a miniature horse. The cervix and bony pelvic opening are next to be encountered. During the birth, it is difficult to distinguish the fully dilated cervix since it is stretched to the size of the birth canal. Behind these structures is the cavernous uterus.

Know your anatomy

Each dystocia situation is potentially different so the first step to remedy the situation is to determine exactly what the circumstances are. Keep in mind that all of this exploratory investigation is going to be done by “braille” so to speak. It is very useful to study the anatomy of your horses ahead of time, particularly the differences in the way that the front and back legs move and attach by “feel”. Much of correcting a dystocia is determining whether there are front feet or rear feet present and whether they are right side up or upside down.

There are a number of different positions that can occur. Just about every one can be corrected if quick action is taken. Once it is determined that there is a dystocia, one must realize that you are “working against the tide”. The mare’s uterine contractions are attempting to expel the foal. In most cases you may temporarily have to push parts of the foal back into the mare’s uterus to get them repositioned. This requires some measure of strength and stamina. The sooner it occurs, the easier it is to accomplish. Since there is significantly more room in the uterus than in the vagina, most dystocias are corrected by pushing parts of the foal back into the uterus or actually going into the uterus to retrieve a front leg, for example. There are occasions when it may be necessary to enter the mare past your elbow to retrieve a misplaced body part to successfully correct a dystocia.

Keep in mind that the mare’s uterus is a large muscle. Once the “water” has been broken, there is no hydraulic pressure to prevent the uterus from contracting. The natural tendency is for the uterus to contract around the foal much as a tube of toothpaste and push the foal through the cervix. The more time that the uterus is allowed to contract around the foal, the smaller the space that the foal will have to occupy until the uterus essentially “shrink wraps” around the foal unless it is born. For this reason it is more difficult to reposition a foal of a mare that has been labor for a long time. This is why veterinarians who arrive after a substantial period of labor may have few alternatives other than Caesarean Section or fetotomy (dismemberment of the dead foal in the uterus).

There is also a loss of the natural lubricating water if action is not taken quickly. Once again the act of repositioning becomes more difficult due to the tendency of the membranes to dry out over time.

When do I break the sac?

Frequently there is a discussion of when it is appropriate to break the bubble or amniotic sac. During the birthing process, the foal is in a period of transition. It is moving from being totally dependent on its dam for all necessities of life through the umbilical cord, to being totally self sufficient after birth. Whether the amniotic sac is broken has no impact on the eventual survival of the foal. The foal must rely on oxygen supplied by the umbilical cord while in the mare and cannot breathe on its own until it is capable of expanding its chest after birth. The amniotic sac does not play much of a function during the birthing process. It does provide a slippery surface to aid the foal sliding through the birth canal. In a dystocia, however, the amniotic sac can become a real hindrance when trying to reposition parts of a foal. It is much easier to break the amniotic sac, reach inside, and grab the actual structures of the foal than it is to manipulate them through the slippery sac. Usually the sac can be torn open with the hands to make an opening.

One useful tool to have on hand to assist with dystocias is a 4 foot long nylon strap with a ring sewn onto each end. If the nylon webbing is 3/8″ to 1/2″ in width it will work well. The strap can be pulled through the rings to make a loop at each end. These loops can be used as snares to be placed around legs to help with repositioning. Soaking the strap in Chlorhexadine (Nolvasan) prior to use will help to prevent introduction of infectious agents into the mare.

Unfortunately there is no easy way to learn or practice resolving dystocias. They are all a “Trial by Fire” scenario. Reading and researching on this subject are about the only opportunities a person has to get ready until the actual situation arises. Those who have access to the internet can find some further information on this subject by using the various search engines and typing in “equine dystocia”. Of course libraries and perhaps even your vet may have a book that you can borrow to pursue greater knowledge on this subject.

The diagrams that are included here show two primary dystocia positions and the brief “textbook” procedure for resolving the mal-presentations. One is called an ANTERIOR presentation which simply means that the foal is coming out head first. The other is a POSTERIOR presentation. Obviously this means the foal is coming out backward.

This particular anterior presentation shows 2 problems. The right front foot is back and the head is back. Essentially the dystocia is resolved in three steps. First, a strap is placed on the left foot above the fetlock joint. This is done to prevent losing this leg. If two loops can be made around this leg with one end of the strap the attachment will be more secure.

Notice the upper arrow in the second diagram. This indicates that this leg is then pushed backward toward the mare’s uterus. Secondly, take the other end of the strap in and locate the neck. Follow it down to the head and locate the lower jaw. Place the loop over the lower jaw. Obviously this is some distance back in the uterus. Carefully guide the head around by applying pressure with the strap on the lower jaw. If this is attempted early in labor it is much easier than if labor has been occurring for some time. By applying pressure to the strap and guiding the head with a hand, the head can rotate forward. The left front leg needs to be kept backward and in the uterus so that there is room for the head to rotate forward, however. With the head rotated, the same procedure is used to get the right front foot positioned.

Take a strap in, identify the front foot by its point of attachment or manner of bending. Slip a loop over the fetlock joint. Cup the hoof with one hand while applying pressure to the strap with the other. Cupping the hoof prevents it from injuring the uterus as it is rotated. Keep in mind that the leg must be lifted upward and rotated forward in the same manner that a horse takes a forward step.

With all parts parts facing in the right direction, the birth can take place. Using hands and straps to guide the front legs and head out in order provides the textbook delivery.

The reality of most dystocias is that only one body part is out of position. This scenario was provided to cover a variety of steps with one situation. Most anterior presentations are a variation of this procedure. A living foal is not real comfortable having its head bent back and will more than likely be working hard to head for daylight. If there are multiple parts out of position, one should question whether there is a live foal in the first place. Usually this can be determined by placing a finger in the foal’s mouth or moving the leg. If the foal is alive it will usually respond by moving its mouth or leg in response to your touch. If the foal is dead, it may be wise to reconsider your intentions to remove the foal and let the veterinarian do the work. Dead foals are substantially harder to work with than live foals since there is no muscle tone and they just tend to “flop” around in the mare.

Posterior presentations are not as common. In this case none, one or both of the rear legs may appear at the vulva. The first step is first to determine in fact if it is a rear leg. This is relatively easy to do by following it up to feel whether you come to the hock joint. Look at the diagram below and notice that with a posterior presentation the bottom of the hooves will be pointing upward toward the mare’s tail. In the case shown, the same applies as before.

Place a strap on the one exposed leg. Push the leg back toward the uterus and then go after the other leg by tracing it from the hip to the hoof. Either slip a loop over the hoof or rotate the leg so that it leg will pass backward through the cervix. Remember to cup the hoof to avoid injuring the uterus. Also keep in mind how the rear leg of the horse moves. The leg needs to be lifted up then straightened out backward as if a horse was springing over a jump. This same procedure holds true if neither leg is present. This is the “Breech” presentation. The foal’s rump can actually plug the pelvic opening and prevent the bag of waters from breaking. All you would feel upon going into the mare is a large bump at the mouth of the cervix where you would expect to find two feet and a nose. If you feel carefully the tail can also be felt through the membranes.

Once both the rear feet are in the birth canal, it is time to assist with the birth. Understand that the foal needs oxygen to remain viable. When the umbilical cord passes into the vagina it will more than likely be pinched off. If the foal is not born in short order, it will suffer from oxygen deprivation and die. Remarkably, foals born “in reverse” seem to come out quite easily with assistance. Time is of the essence in this situation. It is very important that the foal be removed from the mare within a very short time to avoid serious consequences. This requires significant intervention on the part of the foaling attendants to pull the foal and assist with the birth to assure that the time in the birth canal is an absolute minimum.

Other types of dystocias occur that unfortunately we don’t have pictures for but are a reality for miniature horses. These are the “upside down foal”, the “dog-sitting foal”, and the “hip lock”.

Upside Down Presentation

The upside-down foal is a situation where the foal is starting to be born in a forward position but is trying to come out on it’s back with its feet pointing toward the mare’s backbone. The natural arc of the mare’s pelvic cavity and bend of the foal’s torso will not allow this birth to occur. The only option is for the foal to be rotated 180 degrees to the normal foaling position where it is lying on it’s stomach as it comes through the birth canal. First of all it needs to be determined whether this is a posterior delivery or an upside down delivery. In both cases, the pads of the feet will be pointing upward. In this case, a person will encounter the front “knees” and head with the lower jaw upside down behind the upturned hooves. This is a difficult dystocia to resolve. In order to accomplish it, it is necessary to guide one front leg above the head while passing the other beneath the head. Of course all of this has to be done in the mare’s uterus. Placing a strap on one leg and having someone hold and put pressure in the desired direction of one leg helps while a hand is used to guide the other leg around the head in the opposite direction. If successful in rotating the foal, the delivery of the foal will be in the normal position.

Dog-Sitting

Dog-Sitting dystocias occur when the rear hooves of the foal start through the pelvic opening before the hips of the foal. As the foal moves out of the uterus, the rear leg(s) becomes flexed and forms a wedge that prevents the foal from being born. This can occur with one or both rear feet. About the only option available is to push the foal backward partially into the uterus. Then go in beside the foal and carefully push the rear leg(s) back into the uterus to allow the foal’s hip to pass through the mare’s pelvis. These are also difficult dystocias to resolve. Lots of lubricant and assistance is required in most cases to get this one straightened out. There have been a couple of cases where breeders have, upon seeing a rear foot, pulled the foot hard forward to straighten it along the body and the dystocia has been resolved. Pulling only on the front legs without addressing how to unlock the wedge created by the back leg(s) does little but compound the problem when there is a “dog-sitting” dystocia.

Hip Lock

Hip Lock is a situation where all appears well with the foaling and then the foal just stops progressing after it is half way out. Of course the first thing to determine is whether this is a dog-sitting situation or a hip lock. Obviously if it was a dog-sitting dystocia, a rear leg would be found in the vagina. No rear hoof is present with hip lock. With all of the foals we have delivered, we have yet to experience a hip locked foal. Below is the recommendation of one veterinarian as to how to correct the Hip Lock situation.

“Hip lock occurs when a foal’s hips get stuck inside the bony pelvis. The mare’s pelvic opening is shaped like an oval and not a circle. This is supposed to allow for the hips to easily pass through. If the mare is standing pull the foal downward so the hips flip up into the pelvis and then through. If the mare is on her side, first have someone hold the mare’s tail to anchor the mares body. Pull the foal out, arching it slightly upward toward the mare’s tail and occasionally through the mare’s hind legs to pop the hips up and through. If this doesn’t work, do the same but bending the foal to one side to pull one hip through the pelvis at a time.”

Red Bag

Although not actually a dystocia, any discussion of high risk births would not be complete without mention of PLACENTA PREVIA or RED BAG. As its name implies, a red bag appears at the mare starts into active labor. Of course we are all expecting a white bubble. What is all this about? Well, it is the placenta and it has detached from the uterus prematurely. Without the placenta attached to the uterus, the foal has no source of oxygen. This is a critical situation for the foal. There is no time to wait. It is imperative that the placenta be broken when it protrudes from the vulva and the foal is given assistance to be born immediately. Oxygen deprivation occurs in a very few minutes and unless the vet happened to be driving up your driveway, there probably isn’t any use making a call if you want to have any chance of saving the life of the foal.

Break the placenta with your hand. The water will probably gush out. Chances are that the foal is in normal position just behind the placenta, either tear the amniotic sac or hold onto the foal’s legs and assist with the extraction of the foal from the mare. The foal needs to breath very soon! If the foal does not start breathing on it’s own when it is born, straighten out its head /neck to make an air way and give the foal mouth to NOSE breathing. Remember that horses have a very poor airway from their mouth to their lungs. If you are successful getting air to the lungs, you should be able to see the foal’s chest rise with each breath. If you are present for the beginning of the foaling process and you know when the mare started into active labor, the red bag situation usually works out well if you act immediately and get the foal out and breathing. If you find a mare who has been in labor (how long is unknown) and a red bag is present you may or may not have a successful result. All the more reason to be in attendance for every foaling.

It can be very advantageous to stand a mare up when attempting to resolve a dystocia. Obviously some mares will not stand up while in labor but many will. If it is possible to get the mare to her feet, gravity becomes a great help. The mare’s organs and the foal tend to settle back toward her abdomen. In many cases this can provide just enough room to allow the foaling attendant to reposition the foal and achieve a successful birth. Of course the contractions will continue and this is the most difficult issue to deal with while attempting to reposition a foal.

Veterinarians can take advantage of medications to help themselves with the resolving a dystocia. Most highly experienced reproductive veterinarians will take two similar procedures to resolve a dystocia. First they will administer drugs that will sedate the mare and stop the uterine contractions. We have seen this done by the administration of gas in the surgical theatre. In the field or barn environment, we have seen the veterinarians use a combination of Rompun and Ketamine.

Once the contractions have been halted by the veterinarian, the typical procedure is to use some form of “the mare in the air”. In most cases, a bale of hay is used and a piece of plywood is layed upon it to form a ramp. The mare is turned on her back with her hips in the uphill position. The mare is then generously lubricated internally and the repositioning of the foal is made.

The topic of dystocia is certainly not the most upbeat that can be addressed, however, it is a reality that everyone who intends on raising foals needs to be aware of. Whether you as the owner of a broodmare choose to intervene in the case of a dystocia is a value judgement you must personally determine. There are risks involved for your horse at foaling time. It can definitely be a life and death circumstance whether you intervene or choose to wait for professional help.

Fortunately the vast majority of foalings are natural events where we can simply behold the wonder of nature. Being prepared for those occasional births that don’t follow the “textbook”, however, can increase your chances for positive results.

For further information on this topic you may want to consider an internet search using such words as:

Dystocia
Equine Dystocia
Mal-Presentation
Breech Foal
Equine Foaling