The goals of the cesarean section are preservation of the dam and calf and the future reproductive efficiency of the dam. The outcome of the cesarean section is a self-fulfilling prophecy. Numerous variables may affect the successful outcome of this procedure. Case selection is the most important and often overlooked variable. In addition, skin preparation,surgical technique, calf viability at the time of surgery, and exteriorizing the uterus can affect outcome. Minimizing excessive adhesion formation is equally important because it may affect reproductive efficiency adversely. Good surgical technique, including gentle tissue handling, appropriate suture materials and patterns, and adequate infolding of the uterine incision to prevent leakage, combined with antibiotics and anti-inflammatories when indicated can help minimize detrimental adhesions that may affect adversely the future reproductive efficiency of the cow. When dealing with anemphysematous fetus, intensive medical management perioperatively isa crucial determining factor of cow survival. Anti-inflammatories, high doses of intravenous antibiotics, and a ventral midline approach that permits adequate uterine exteriorization and reduces abdominal contamination also are likely key elements that contribute to the high survival rates of cows with emphysematous fetuses.