Caesarean Section

Question 1

What percentage of dystocia cases can be managed with medical therapy and manipulation?

Answer 1

20 - 40% of cases

Question 2

Maternal indications for caesarean? (4)

Answer 2

Prolonged gestation (>70 days c.f. normal 63 +/- 2 days)

Primary uterine inertia refractory to medical treatment (>6 hrs)

Secondary uterine inertia (> 2 hrs between puppies)

Maternal pelvic abnormalities

Question 3

Foetal indications for caesarean? (4)

Answer 3

Foetal oversize

Small litter - often large foetus and primary inertia due to little hormonal initiation from the foetus

Foetal malpresentation

Foetal death - if unresponsive to oxytocin and supportive care

Question 4

Why is manual reposition hard?

Answer 4

Due to the size of bitch/ queen it is difficult and leads to iatrogenic damage of the foetus (30 mins of active straining)

Question 5

What is iatrogenic damage?

Answer 5

illness caused by medical examination or treatment

Question 6

What is uterine inertia?

Answer 6

abnormal relaxation of the uterus during labour causing a lack of obstetric progress

Question 7

Why is ultrasonography useful during dystocia?

Answer 7

can be useful in assessment of foetal viability.

Question 8

Emergency pre-op C-section considerations

Answer 8

Is the patient compromised?
Circulatory status +/- sepsis

Question 9

What can be used for crystalloid replacement?

Answer 9

balanced electrolyte solution +/- glucose or dextrose

Question 10

Considerations for +/- desexing during c-section

Answer 10

May prolong anaesthesia/ surgery

May save a subsequent procedure

Be mindful of loss of circulating volume

Question 11

How to minimise risk of aspiration pneumonia?

Answer 11

Food is rarely withheld

Use prokinetic metoclopramide to increase lower sphincter tone

Also careful ET tube cuff inflation and removal

Question 12

C-section timing

Answer 12

Time from anesthetic induction to delivery of pups should be as short as possible

Prepare as much as possible before induction (clipping, skin prep, equipment setup, staff ready for puppy care)

Question 13

C-section anaesthetic goals

Answer 13

Maximise dam safety
Minimise foetal depression

Question 14

C-section incision

Answer 14

Ventral midline approach
2-3cm cranial, 5-6cm caudal to the umbilicus

Needs to be a large enough approach to allow the uterus to be exteriorised quickly

Question 15

Why do you need to be careful of when making the c-section incision?

Answer 15

Take care not to damage the abdominal contents particularly the gravid uterus

Question 16

Once exteriorised, what do you need to do to the uterus?

Answer 16

Pack off the uterus from the abdominal cavity with laparotomy sponges
- be careful not to tear the uterine vessels or uterus

Question 17

Where do you incise the uterus ?

Answer 17

In an avascular area within the body that will allow removal of foetuses from both horns

Sometimes multiple incisions are required

Question 18

How to get the puppies out (4 steps)

Answer 18

1. Milk each foetus individually down the horn to the uterine incision (avoid swinging in arc as has been implicated as a cause of brain damage)
2. Break through the foetal membrane
3. Clamp the umbilicus 2-3cm from its base
4. Rub the foetuses vigorously to stimulate breathing

Question 19

What drug can be used to stimulate breathing in puppies?

Answer 19

Sublingual dopram
0.2-1mg (1 drop)

Question 20

What do you need to check before closure?

Answer 20

If all foetuses are removed
Include check of uterine body and vagina

Question 21

C-section closure

Answer 21

Single or double uterine closure
- simple continuous inner - submucosa not into lumen
- continuous inverting outer
3/0 - 4/0 monofilament, absorbable
Taper point needle

Question 22

What do you need to do in between closing the uterus and the abdomen ?

Answer 22

Change gloves and instruments

Question 23

What do you do to the uterus before returning it to the abdomen ?

Answer 23

Thoroughly lavage it

Question 24

3 complications of c-section

Answer 24

Haemorrhage - intrauterine or peritoneal (ligature failure)
Infection - long procedure or gross contamination
Foetal or maternal death