Uterotomy sites should be closed using a 3-0 or 4-0 monofilament absorbable suture in a single-layer continuous appositional or inverting pattern (eg, Cushing, Lembert) or using a 2-layer closure with the second layer inverting the first. Myometrium and submucosa should be included in the closure, and luminal penetration should be avoided.
After uterine closure, local lavage should be performed with sterile saline while the uterus is still isolated from the abdominal cavity with sponges. This can be followed by abdominal lavage using warm sterile saline (100-200 mL/kg). Limited abdominal exploratory should be performed to ensure no other pathology is present. Sponges and hemostats need to be counted prior to abdominal closure to prevent retained foreign material.
Abdominal closure is routine. An intradermal skin closure pattern (Figure 3) is ideal to prevent milk or fecal debris from encrusting on suture tags, as puppies will be active in the area of the incision when nursing. An impermeable bandage can be used to protect the incision from contamination during nursing. If a line block was not performed prior to surgery, it can be completed at closure, or a transversus abdominis plane block can be performed with ultrasound guidance prior to recovery to minimize the need for opioid analgesics.
The dam should be recovered quickly to facilitate early nursing and maternal bonding. Close observation is needed after initial introduction of the puppies to ensure the dam is adequately recovered and receptive. This can help prevent inadvertent or intentional maternal injury to the puppies. After the neonates and dam are stable, they should ideally be returned to their home environment to reduce stress.
Maternal pain can be managed with a single postoperative dose of an NSAID (eg, meloxicam, 0.1 mg/kg IV) and an opioid analgesic (eg, methadone, 0.05-0.2 mg/kg IV every 4-6 hours) as needed for pain.7 Limited research has been done on the effect of pain medication on nursing dams and their puppies, although it is estimated that 1% to 2% of the maternal dose reaches the neonates.7 Repeat doses of NSAIDs should be avoided to minimize exposure to the developing neonatal kidneys.
Use of opioids that are less lipophilic (eg, morphine, hydromorphone, methadone) as needed after pain scoring the dam will decrease neonatal exposure.7 Neonatal adverse reactions to opioid exposure can be minimized via nursing immediately prior to opioid administration, active surveillance of neonatal behavior for respiratory depression and lack of vigor, and intervening with naloxone (1 drop of 0.4 mg/mL formulation under the tongue) to reverse any adverse effects.
Antibiotics are not necessary after uncomplicated cesarean section. When antibiotics are indicated (eg, mastitis, metritis), beta lactams (eg, ampicillin, cephalexin, amoxicillin ± clavulanate) are most often used.8