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Karine J. Onclin, DVM, PhD, Diplomate ECAR & John P. Verstegen III, DVM, MSc, PhD, Diplomate ECAR
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While cesarean section is a common surgical procedure, it may be associated with significant mortality in both dams and puppies. Timing is extremely critical for puppy survival for both emergency and elective c-sections. If delivery is delayed by more than 24 hours after the start of the second stage of labor, the loss of all puppies due to placental detachments usually ensues. Emergency c-section should be performed as soon as possible after it is determined that labor is unproductive, before the occurrence of dam exhaustion or distress of the puppies and/or the dam.
Close coordination of the surgeon, anesthetist, and nursing staff is critical. Good preparation of the dam, correct selection of the anesthesia protocol, fast surgical delivery, and adequate neonatal care are the keys to complete success. Ideally, the dam should be totally awake as soon as possible after the procedure to allow for development of the neonatal/maternal bond and maternal adoption of the neonates. This point is critical when considering anesthesia and surgical protocols.
Related Article: Dystocia Diagnosis and Management
Procedure Pearl: It is important to master each of the surgical steps to reduce the length of the procedure.
Preparation of the Dam
Related Article: Dystocia in the Bitch
Selection of Anesthesia
The main concerns when choosing the anesthesia protocol are:
Ideally, the anesthetic drugs should:
Procedure Pearl: Phenothiazines, barbiturates, ketamine, and atropine can all pass through the placenta and can affect the ability of neonates to thrive. Ideally, they should not be used.
The Surgical Procedure: Step By Step Cesarean Section in the Dog
1. Administering the anesthetic Before making the incision, administer a local midline block. Inject lidocaine (0.5% to 1%, without epinephrine and after dilution with sterile water or normal saline), IM and SC along the incision line. (This may also be done in the preparation room if there is adequate time, which significantly reduces anesthesia duration.) Never exceed a total dose of 10 mg/kg of body weight. Lidocaine provides necessary analgesia during the initial steps of surgery. If used, opioids should be administered only after delivery of the puppies, thus reducing potential neonate depression. Readministration of long-acting local anesthetic can be used at closure, minimizing need for opioids.
Procedure Pearl: Fluoroquinolones should never be used because of their negative effects on neonatal development and growth.
2. Use of antibiotics A one-time preoperative IV injection of antibiotics may also be administered before induction, using a broad-spectrum cephalosporin. However, it is generally not needed, particularly for an elective c-section where there is no abnormality in the general condition of the bitch and no infection of the uterus. Fluoroquinolones should never be used because of their negative effects on neonatal development and growth.
Procedure Pearl: Traction on ovarian pedicles may induce a vagal reflex, leading to hypotension and bradycardia; lidocaine helps prevent such a reflex.
The location of the incision allows rapid removal of 2 puppies or more. The cranial intercornual septum prevents a puppy located in the opposite horn or in the uterine body from being exteriorized through the contralateral incision. The rupture of the intercornual septum (directing puppies to the uterine body during whelping) can cause serious hemorrhaging. Always make an extra opening rather than lose time or risk contamination or rupture of the uterus by trying to remove all fetuses from a single opening. The number of openings will depend on the number and size of fetuses. It is most often 2 or 3.
Give the puppy to the nursing team, who will take care of its complete resuscitation and homeostatic balance. Ideally the nursing team should include at least one person per pup. Leave the placenta in situ; all placentas
Repeat the procedure for all fetuses, making as many incisions as needed in the first and then second horn of the
It is critical that the placental detachment occur between the fetal part of the placenta (trophoblast) and the endometrial part (C). If both layers of placental tissue are removed, there will be no uterine mucosa (endometrium) remaining; and an ovariohysterectomy may become necessary.
To assist in placental detachment, it is sometimes necessary to use one finger positioned between the fetal placenta and the uterus while simultaneously exerting gentle traction on the cord (C). Repeat the detachment procedure for all placentas.
Remove or Leave in Place?Placentas are easy to detach when the c-section is performed at the expected due date (emergency c-section for a dystocia or perfectly timed elective c-section) but may be more difficult in preterm animals. Similarly, bleeding from the maternal endometrium is not a great concern when the c-section is perfectly timed, but it can be profuse if the surgery is performed too early. For this reason, difficult-to-detach placentas are more and more often left in situ to be expelled naturally during the next few days or resorbed.
Close the uterine incisions using a continuous inverted pattern (A) (Cushing or Lambert), with a 3-0 or 4-0 absorbable material (PDS, Vicryl; Ethicon, www.ethicon.com) on a taper-point needle. The suture should pass through the myometrium and submucosa, but should not be visible in the lumen of the uterus (it doesn't cross the entire endometrium). It is critical to tighten properly to make it as hermetic as possible. Having an assistant hold the uterus is a great help.
After closing the incisions, inject oxytocin, 1 to 5 (maximum) IU IV per dog. Check uterine contractility and incision sites for possible leakage. If the uterine sutures are leaking, a second tight continuous inverted pattern suture can be placed on top of the previous one. If a Cushing pattern has been used first, the second suture should be a Lambert pattern and vice versa.
Wash the uterus with physiologic saline to remove all blood clots, fibrin, and uteroverdine, which can promote the development of adhesions with the omentum (B). If the abdomen has been contaminated by fetal fluid (which generally happens), flush it with warm saline before replacing the uterus.
Close the abdomen routinely. Ideally the skin incision should be closed using an intradermal continuous pattern with 3-0 or 4-0 absorbable material. Any other kind of skin suture (staples, interrupted stitches, etc) can be susceptible to sucking by puppies, which can be a source of postoperative complications (dehiscence or infection). Do not puncture the mammary glands during closure.
OxytocinIn an animal undergoing a c-section because of obstructive dystocia, uterine contractions have been ongoing for a long period prior to surgery; in such cases, the uterus may not be able to contract after the oxytocin injection. A second injection (same dose) is administered; higher doses of oxytocin are never recommended as they induce paralytic contraction of the uterus and desensitization of the receptors. If there is still no contraction, an ovariohysterectomy should be considered to prevent complications related to poor or absent uterine involution. Ovariohysterectomy done at this time does not affect milk production or release and will not prevent normal maternal behavior and nursing.
After the ProcedureIdeally, the dam will be totally awake soon after the procedure. She and her offspring should be returned to their natural environment as quickly as possible to facilitate establishment of the neonatal/maternal bond. Being in the comfort of their own environment reduces postoperative stress and mediates associated behavioral and lactation problems. For pain, NSAIDs and drugs like tramadol are always preferred to opioids, which are often associated with depression, hypothermia, and modified maternal behavior.
Advantages & Disadvantages of Uterotomy Techniques Single incision into uterine bodyAdvantages
Multiple uterine horn incisionsAdvantages
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