"Most of the time, foaling is uncomplicated. It's those rare occasions that something goes wrong," notes Jennifer Schleining, DVM, MS, Iowa State University College of Veterinary Medicine. "Then you've got some pretty important decisions that you have to make readily. You may have to decide, if I had the option, do I want to save the mare or do I want to save the foal? Time is of the essence — you have a relatively small window to get the foal out properly to save the foal or the mare or both."

“Red bag delivery” is a layperson’s term for premature separation of the placenta prior to or during a mare’s foaling. Fortunately, it is an infrequent occurrence in healthy foaling mares. However, when it does occur, prompt action is required to prevent a stillborn or weak foal.
 

The foaling attendant must know that the equine placenta is made up of two major parts: the red bag or chorioallantois, and the white bag or amnion. The red bag attaches to the uterine wall and allows the exchange of nutrients and waste back and forth to the fetus through the umbilical cord. The white bag surrounds the fetus and has many functions, including lubrication and protection. During a normal foaling, the red bag breaks just prior to the foal entering the birth canal. Thus, the first portion of the placenta you see in a normal foaling is the amnion, or white bag, followed promptly by the fetus it contains.

In a normal delivery, the red bag is generally passed by the mare within three hours after foaling. When the red bag appears before the white bag, it means that a portion of the placenta has detached from the uterine wall prematurely, reducing or eliminating the exchange of nutrients to the fetus still inside the mare. In this situation, the red bag appears as a red “velvety” bag hanging from the vulva. When the foaling attendant confirms the presence of the red bag instead of the white bag, he/she should carefully open this bag with surgical scissors—inside will be the white bag enclosing the fetus. Check for two legs and the nose; tear open the white bag and deliver the fetus promptly as it may be short on oxygen due to the early placental separation. The foal should be watched carefully for signs of hypoxia (oxygen deprivation) or infection.

Why do red bag deliveries occur? The normal chorioallantois is relatively thin and breaks easily during birthing. However some placentas are thickened from infection or inflammation, a condition called “placentitis,” and can result in red bag deliveries. Exposure of late pregnant mares to fescue grass can also result in a thickened placenta at foaling. High-risk mares that have had abortion, stillborns or weak foals previously can be evaluated by ultrasound in late pregnancy for placentitis or a thickened placenta. Also keep in mind that even a well-handled red bag delivery may result in a compromised foal.

Andy Schmidt, DVM, MS, Diplomat ACT, is based in Oconomowoc, Wis., at the Wisconsin Equine Clinic & Hospita

Photo 1: Obstetric chains applied to a foal in a breech presentation. Note the mare is still standing before extensive contractions begin.

"I think that there's definitely a difference between the most common complications that you see and the most life-threatening things that you see," Wolfsdorf says. "You might be presented with a mare that has a dystocia that ends up with postpartum metritis or a deeper infection in its uterus that can have a vulvar discharge, which needs to be treated. This can be successfully treated with uterine lavage, intrauterine and systemic antibiotics, anti-inflammatory medications and oxytocin."

Most of the problems are those that affect the mare. "Obviously, if we can get a live foal, that's what we want. But we also want to be able to send home a reproductively normal mare so she can continue to produce foals," Sheerin says.

"The first stage of parturition is the one that the mares themselves can manipulate, and they can put off labor until it's the middle of the night when nobody is watching," says Schleining.

Photo 2: The mare is now in lateral recumbency as contractions become more powerful. Assistants continue to apply tension on the obstetric chains with a veterinarian helping position the foal in the birthing canal.

Dystocia

The most common foaling abnormality is a dystocia, in which the foal is coming out in an abnormal position rather than feet and head first. For example, a leg or the head may be back or the foal may be coming out backward. (See Photos 1 through 4, to better understand a breech position delivery.)

Photo 3: The foal is now halfway out. The umbilical cord can be seen in the veterinarian's left hand.

Photo 4: One final push before the foal is completely out. The rib cage is just now visible.

"With the dystocia," says Sheerin, "if you're working with it on the farm, you have a limited amount of time for your manipulations before you decide to refer it or, if referral is not an option, to do something more aggressive." Dystocia that cannot be corrected on the farm and requires referral can have a more serious prognosis. The outcomes of the mare and fetus are often tied to the length of time of dystocia prior to resolution.

"In central Kentucky, we have the luxury of sending everything into the clinic, so the majority of dystocias are sent to the clinic if we can't get them resolved at the farm," Sheerin notes. "Once at the hospital, we'll anesthetize the mares, raise their hind ends, and then do the manipulations that are necessary. In most cases, we can have a controlled vaginal delivery, and then everything is fine." If a practitioner is faced with a difficult case on the farm and the client is a great distance from a referral center, it's best to send them early.

Retained placenta

Photo 5: This photo depicts a retained placenta. The placenta is tied in a knot hanging from the vulva to apply tension through gravity on the endometrial attachment.

Retained placenta may not be obvious, such as when the whole placenta is retained and hanging from the vulvar lips. "Occasionally, just the tip of a nonpregnant horn may be retained, and if you don't examine the placenta routinely and completely, you can easily miss a piece of placenta," Wolfsdorf says. "If you miss a piece of placenta, then you set yourself up for metritis, endotoxemia, septicemia and laminitis. Eventually, the mare may end up with serious complications. Make sure you examine each placenta completely. Turn it inside out so that the velvety or chorionic surface can be viewed since this is the surface against the endometrium and is most likely to show pathology. In addition, you will be able to identify the tips of both horns by the avillus portion where the oviductal papillae resides."

"With a normal mare that has retained her placenta, I will start uterine lavage as soon as I examine the mare," says Sheerin. "If a majority of the placenta is retained intact, we perform the Burns technique, in which the placenta is filled with fluids and the fluids are held in the placenta for a period of time. We then remove that fluid and treat the mare with a small dose of oxytocin. Most mares will pass their placenta after this treatment. These mares are also given systemic antibiotics and anti-inflammatory drugs."

For mares that have had a uterine artery bleed as well as retained placenta, the procedure is somewhat different. "I will wait probably 24 hours before I start to do anything with the mare, and then the things I do, I do in slow increments," says Sheerin. "I will examine her and perhaps do a little bit of gentle manipulation to allow the placenta to be passed." If the mare stops pushing and enough of the placenta is sitting in the uterus, there's not enough gravity to pull it out. If you can exteriorize a portion of it, then gravity will kick in and slowly break down the attachment, and the mare will pass it. But don't start just tugging on it; gentle traction will suffice.

"If I do lavage on these mares, which I generally start within 24 to 48 hours after foaling, I use small volumes of fluid so I'm not distending the uterus too much," says Sheerin. "A liter or two, flushing it in and out, is adequate. I may do that many times to try to dilute out any potential bacteria, so we avoid dealing with septicemia or endotoxemia as well."

Periparturient hemorrhage

Obviously life-threatening, most cases of periparturient hemorrhage occur in older, multiparous mares. But, recently, it is increasingly seen in primiparous mares of almost any age, 5 to 24. "Hemorrhage may occur from the middle uterine, external iliac, utero-ovarian or vaginal/vestibule-vaginal arteries in late pregnancy and after parturition, and it accounts for 40 percent of periparturient deaths in mares," states Wolfsdorf.

You can see different levels of hemorrhage in these mares. A mare may hemorrhage prior to foaling and exhibit mild, colic signs, or you may find the mare dead. More commonly, a mare hemorrhages after foaling, which may occur from a couple of hours to a couple of days postpartum. "The majority of mares hemorrhage postfoaling or within 24 hours of foaling," says Sheerin. "But we've had mares that hemorrhage prefoaling as well as mares that hemorrhage as far as a week out from foaling."

Three different types of hemorrhage can occur, according to Wolfsdorf. First, mares can rupture a uterine artery and bleed into their broad ligament. This type is usually self-limiting, contained within the ligament by hematoma formation. Affected mares may be mildly to moderately painful and will usually show signs of colic and discomfort and eventually develop mild signs of shock.

A second, more severe and more life-threatening type occurs when the hemorrhage leaks out of the broad ligament intra-abdominally, and the mares go into full-blown shock.

The third type involves intrauterine hemorrhage in which there may be an artery or a blood vessel within the uterus that leaks or is torn during parturition, and the mares bleed into their uterus. "That is usually a more subtle scenario in which you may just find blood coming out of the mare's vulva when she walks or lies down since the uterus gets full," says Wolfsdorf. "When she moves around, there may be a trickle of blood or clots that come out of her uterus."

Veterinarians have a variety of options to treat these mares. "In my experience, it is important to keep mares quiet in a dark stall and keep them sedated, if needed, as well as comfortable with anti-inflammatory agents such as banamine," says Sheerin. "Once we determine that a mare is indeed bleeding, we'll use naloxone, which is an opiate antagonist useful for treating shock, and sedation. We may start the mare on fluids and use aminocaproic acid, which is used in people with hyperfibrinolysis-induced hemorrhage, plus or minus corticosteroids as well as additional fluids. Using fluids obviously is controversial, in that are you going to possibly increase the blood pressure too much by increasing the volume or replacing the volume. Nobody has come up with an answer because it is something that is hard to do any sort of controlled study on, so the evidence is only anecdotal. Thus, the decision is made on a case-by-case basis."

Sending these mares to a referral clinic may add additional stress, increasing blood pressure and possibly causing the broad ligament to rupture. "If there is a complete rent in the broad ligament because of the bleed, and the mare is bleeding profusely into its abdomen, then there is nothing you can do to save it," Sheerin says.

Other complications

During the violence of foaling, and with dystocia, various tissues may be torn. The anatomy of a malpositioned foal can do damage. "If the foal's feet are not positioned correctly, they can damage the cervix and the vaginal vault, and they even can go up dorsally and penetrate through into the rectum," says Wolfsdorf. A foal's feet may come out of the mare's rectum instead of out of the vulva. This scenario may be more common in maiden mares because they haven't relaxed as well and don't dilate as well. "But these injuries are repairable," Wolfsdorf states.

Other kinds of complications are commonly seen but are less severe, including rectovaginal tears, which can occur when a Caslick's procedure has not been reversed prior to foaling or from a large foal. This kind of tear occurs when the foal tears the mare's vulva lips or perineal body, which can develop into a rectovaginal fistula. Other injuries can also occur like bruising post foaling or vaginal and cervical tears. These may have consequences to a mare's fertility, especially with cervical tears, but they are not generally life-threatening.

Another common foaling complication is colic from colon torsions. "We're not sure why it happens exactly," Wolfsdorf says, "but there's a belief that once the mare has had the foal, there is increased space in her abdomen. So she starts eating more because there's less pressure on her stomach. This may result in an increased buildup of gas that causes the colon to torse." With early diagnosis and prompt surgical correction, successful outcomes are possible. But if diagnosis is delayed, it may have a devastating outcome.

Complications associated with straining are not necessarily as common but are equally severe, such as rectal or uterine prolapse postfoaling. Tears in the vagina can also allow the small colon to protrude through the vulvar lips. It's not common, but it is serious, with serious implications.

Foaling should be uncomplicated, but the force of the act, or the unusual positioning of the foal, may change the outcome dramatically. Being prepared for the range of possible complications or injuries is essential to mare and foal wellbeing.

Ed Kane, PhD, is a researcher and consultant in animal nutrition. He is also an author and editor on nutrition, physiology and veterinary medicine with a background in horses, pets and livestock. Kane is based in Seattle.

Wrapping the tail (note that ground tying the mare to do so may not be recommended with all mares!)	The wrapped tail will prevent stray hairs interfering with the foaling process, and also keep the tail cleaner	During the early stages of labor, it is not unusual for the mare to get up and down several times. She is typically repositioning the foal, or may just be plain uncomfortable!
There can be a lot of "hurry up and wait" during stage 1 of labor! Mares have even been known to remain in this stage for a day or more! Monitoring is recommended, and if in doubt, consult your vet!	Sometimes the mare will appear to stop being uncomfortable and wander off and eat for a while, or possibly eat and scratch her butt in this case...	...only to resume signs of discomfort a little later - biting at the flanks, or signs suggestive of colic are typically indicating uterine contractions.
Don't confuse urination with the "waters breaking" - there's a lot of pressure on that bladder, so frequent urination with low volume is common!	Finally the mare does lay down, and...	...very shortly afterwards, the "waters break" - meaning that allantochorion ruptures, and the allantoic fluid is released. The allantoic fluid will look a lot like urine - and it is in fact comprised primarily of fetal urine.
Within 20 minutes of the passage of the allantoic fluid, the white amniotic membrane should become visible. If the membrane that appears is red, do not hesitate to intervene and rupture that membrane manually, seeking the white membrane within, and manually encouraging passage of the foal. A red membrane is indicative of a "red bag delivery", meaning that the allantoic membrane failed to rupture, but rather is separating from the lining of the uterus, and the foal is in danger of suffocation.
Within the white membrane, you should now see the appearance of a foot, followed shortly by another foot, and then the nose. If you have seen the appearance of the white membrane, and no foot within 20 minutes, or a foot and no second foot or the nose within 15 minutes, you should - if experienced in foaling - determine the position of the foal, or if not experienced, get your veterinarian out - you may be looking at a dystocia (malpresentation) situation, and time is of the essence to achieve a healthy outcome (and even then, you may not).
Hopefully now the foaling will move ahead with the minimum of difficulty. Many people feel the uncontrollable need to step in and "help" the mare, but unless there is an obvious inability on the mares part to be able to pass the foal herself, leave them alone! Unnecessary interference at this stage can give rise to all kinds of future complications ranging from cervical damage (due to pulling before the cervix is adequately relaxed) through to a mare developing uterine inertia - a lack of desire to push - in future foalings, as she is waiting for someone else to do the work (and this may be a major issue if that someone else is not there to assist!)
Notice the natural passage of the foal toward the hocks. If assistance is required, in most situations pulling toward the mares hocks in conjunction with the contractions is recommended. There may be some emergency situations where this is not recommended, and rapid extraction is desirable, but in most cases the "toward the hocks in conjunction with contractions" rule will apply. Once the chest is out of the mare, manual rupture of the amniotic membrane should be performed if it has not naturally occurred. Note that the foal cannot breath until its chest has passed out of the mare and is able to expand (and draw in air). Remember too that there will still be oxygen transfer achieved through the placenta and umbilicus until the shut-down of placental-umbilical blood movement and separation of the umbilicus.
As long as the mare is quiet and prepared to remain laying down, we like to gently manipulate the foal toward the mare where she can see it easily, and possibly touch it. We try avoid disruption at this stage to keep the mare down as long as possible, as we want the umbilicus to separate naturally rather than prematurely by the mare getting up or moving. The natural separation indicates the close-down of placental blood transfer, and although if there is a premature separation, the amount of blood loss is minimal (although it looks a lot!), and not a major cause for concern, the natural shut-down process has been associated with increased uterine contractions and a lower incidence of retained placenta, so awaiting the natural rupture of the umbilicus is usually preferable.
At the time of umbilical separation - natural or not - placing the hand on the foal's abdomen while gently pinching the umbilicus is desirable to provide abdominal support. This reduces the stress placed on the umbilical/abdominal junction, and reduces the likelihood of an umbilical hernia. Once separated, the umbilicus should be dipped in a solution of ½% chlorhexidine. Iodine has been used by many for years, but has been found to be caustic enough to actually cause tissue damage and increase the risk of umbilical damage, leading to a potentially higher incidence of patent urachus or even umbilical hernia. There is however a need to dip the umbilical stump more frequently with the chlorhexidine - 3 or 4 times a day is recommenced for the first 3 or 4 days, or until the stump is dry and sealed. Take a piece of string, tie up the placenta to itself to avoid the possibility of the mare stepping on it while rising or waking after foaling - either of which could result in breakage of the membrane, and a loss of hanging weight that encourages complete passage of the placenta. This would result in a higher risk of retained placenta. We then like to move the foal within easy reach of the mare, and withdraw ourselves while monitoring the situation from a little distance away, allowing the mare and foal to bond.
The foal will usually try to get up before too long - often with some ungainly results! Again, don't feel a need to rush right in there and become involved - the foal is learning, and if the foaling area is safe will be unlikely to come to any harm even though the crashes can look quite bad! Remember how many times you skinned your knees as a kid?
Before too long, the foal will most likely start to look seriously organized about getting up, or the mare herself may show signs of wanting to rise. It is desirable to wash off the mares udder at this point, using just warm water, and prior to the foal nursing. Research has shown that washing the udder prior to nursing significantly reduces the incidence of neonatal septicaemia - which makes a lot of sense when one thinks about it, as the udder is not really very clean, and the foals gut can absorb any large molecules it encounters within about the first 12 hours after birth. Preferably those large molecules will be immunoglobulins in the colostrum, imparting antibody protection, but they could be bacteria as well, so the fewer bacteria encountered, the better!
The foal will probably get up soon, and be more organized about how it tries, so now a little assistance may be beneficial - just a balancing hand is best, a bit like you're teaching your child to ride a bicycle... be ready to prevent a serious crash, but just assist with balance if you can! Eventually those long legs will get set at each corner, and the foal will be standing alone - albeit a little wobbly!
It is worth noting that even though this appeared to be a textbook foaling of this maiden mare, with no complications, she did retain her placenta for about 4 hours. Upon dropping it (after oxytocin treatment), evaluation showed that there was a piece missing, and we were obliged to retrieve it manually from the uterus. This clearly demonstrates that it is important to maintain careful monitoring not only prior to and through the foaling period, but also afterward! If this mare had been left to foal unattended without monitoring, although the foaling itself would have passed "without a hitch", the mare would have become severely sick and quite possibly have died as a result of the piece of placenta that broke off and was retained within the uterus. Had the mare been left to foal outside unattended, it is most likely that some sort of scavenger would have retrieved the placenta before a human, and evaluation - showing a piece missing - would have been impossible. The sequela would almost certainly have been a severely sick mare 24-48 hours later. It therefore goes to show that one can never be too watchful at foaling time!