• The best emergency c-section is the one that is avoided altogether- partner with local rDVMs that are comfortable with repro cases and how to manage them. Understand the stages of parturition and how to coach an owner through the stages. 

  • Once any sign of fetal distress is detected, you should make the decision to go to surgery. Remember that a c-section is about saving the fetuses and that the overall health of the dam should also be considered. If the dam is not in distress (due to uterine trauma/fetal obstruction) and the undelivered fetuses are not viable there is NO need for emergency c-section. Fetal heart rates below 180 is a clear indicator to go to surgery. Other signs include: 

    • Green discharge without a puppy in 1-2 hours (warn owners the puppies may not be at term, the dam may be aborting as this is a sign of placental separation) 

    • Obstructive dystocia (narrow pelvic canal, large fetuses, vaginal anatomic abnormalities) 

    • Take into consideration the breed (brachycephalics are high risk), the age (older dams are high risk), and if previous c-sections were needed 

  • If you are questioning if the babies are at term (which is very common as unfortunately the vast majority of emergency c-sections will be from inexperienced breeders) try to use the below information to make an informed decision: 

    • Any sign of GI movement in fetuses on ultrasound 

    • Dental pads 

    • Kidney architecture 

    • Calcification of extremities 

  • Anesthetic considerations 

    • The name of the game is to keep isoflurane as low as possible and to keep time under anesthesia as short as possible 

      • All prep work done awake (including dirty scrub) 

      • Pre-oxygenate 15 minutes (do this while shaving- be efficient) 

      • Consider a local line block- be careful not to hit a mammary gland (you can also do this at close if it is adding to the prep time/you or your team are not fast)

    • Avoid anything that is very sedative to the babies

      • Fentanyl CRIs are a no, midazolam is out, no ketamine 

      • You can use fentanyl as a bolus on induction 1-3 ug/kg (low dose and it does cross the placental barrier)- be ready for the catch team to reverse babies with naloxone if needed- one drop sublingually 

    • The most important thing when picking your drug protocol is that you and your team are comfortable with the drugs used

    • Cerenia is not labeled for puppies younger than 8 weeks due to bone marrow suppression, does not address regurgitation 

    • Ondansetron and Reglan can and should be used 

      • Really for any airway dog these two drugs should be part of your protocol 

    • Cefazolin pre-op as usual (if you’re having to give a second dose, the surgery is too long)

    • If the dam is very stable and has a low ASA score: 

      • Dexdom as a pre-med if patient is very stressed or fractious, hydro or methadone at induction or shortly after airway is secured 

      • Propofol bumps as needed, do NOT use a CRI of propofol 

      • Once the puppies are out, you can up your pain game and turn up the iso and finish the close 

    • If the dam is not stable: 

      • Stabilize (easier said than done- identify problems: CV add a pressor if needed, dehydrated bolus those fluids, low glucose/low calcium fix em up)

      • Then similar drug protocol should be able to be used 

    • The author of the linked paper has an ideal flow for a c-section including drug protocols and choices

    • Carprofen is a yes- give at any time during this process and can send home 1-2 doses 

    • Gaba can be considered TGH as well

    • Once the patient is intubated and iso is on- you should be cutting within 10 minutes 

    • The nursing staff on the case should be very careful when extubating (true for any at risk patient/breed) 

    • You can consider oxytocin post-op (1 unit/dam IM) to help with post-op hemorrhage, but is often not needed if puppies are suckling as the dam will naturally secrete this

  • Below resources to send home with pet parents- there are many TGH templates available as well. These dams should be going home same day unless there was a complication 

  • OHE at the time of a c-section is not always in the dam’s best interest. Pick the ethical lines and boundaries you are willing and not willing to cross and have an open and non judgemental conversation with the owners. If spaying, take that into consideration when making your post-op plan as they will be more painful and risk of hemorrhage is higher

  • Specific surgery considerations 

    • Two layer close of the uterus 

    • Hand off on a mayo stand that has a sterile huck towel on it to prevent dropping or accidental contamination 

    • Make sure your team is assembled prior 

    • Consider APGAR scoring puppies 

    • Bradycardia for dam- consider glycopyrrolate if available over atropine, as atropine does cross the barrier and affects the babies

Medical Management Takeaways 

  • Uterine inertia is the most common cause of dystocia

    • Old dam, comorbidities, too few fetuses to trigger normal parturition cascade (1-2 puppy litters high risk), genetic 

  • Obstructive dystocia 

    • Uterine torsion or rupture, inguinal herniation, vaginal/vulvar abnormalities, narrow pelvic canal/fetal malposition/fetal monster

      • For malpositioning, so much lube and lube with a red rubber catheter cranial to the fetus (IF it is not too big for the vaginal canal)

      • Grasp by neck/pelvis do NOT grab a limb or a tail…you can very easily pop these off…use gently ventral pressure (ventral to the dam)

      • Vestibulovaginal obstruction- gently stretch or consider an episiotomy 

      • If you can’t manipulate the puppy into a normal position, you can consider gentle abdominal and rectal manipulation 

      • Last resort that’s a little odd: put the dam in a wheelbarrow position and let her chill for a bit, this MAY allow gravity to pull the uterus cranially and shift things so the puppy can be repositioned 

    • If these don’t work, c-section (and don’t mess around too much, always check the babies periodically and make sure fetal heart rates are strong) (Study cites that neonatal mortality increased from 5.8% to 13.7% if intervention was delayed beyond 5 hours after stage II labor has started)

  • Once obstruction has been ruled out: 

    • Is there a strong ferguson reflex? 

      • No? R/o low glucose/low calcium 

    • Fetal HR <180 → straight to a c-section 

      • If they’re below 150, this is severe distress and step on the gas 

    • If there are more than 4 puppies left, medical management has a higher chance of failure 

    • Two big medications to use when trying medical management: 

      • Calcium gluconate and oxytocin- give these together 

        • CaGluconate strengthens uterine contractions 

        • Oxytocin causes the contractions 

      • Calcium gluconate: IV dose of 10% 10-20 mg/kg SLOW with leads on 

        • Same dose SQ, dilute it if using the 10% 1:1 

      • Most hospitals have the 23% (and it is much more cost effective) 

        • Quick and dirty- calculate the 10% dose, pull up half of that from the 23% and then dilute it 1:1 

      • Can be repeated in 6-8 hours if needed

      • Oral calcium for dystocia medical management not effective (see eclampsia for oral dosage)

      • Oxytocin dose 0.25-1 unit PER DAM 

        • No more than 5 units (higher doses cause fetal hypoxia and uterine tetatny)

        • 2-3 doses can be given every 15-30 minutes, once you’ve hit this medical management has failed and a c-section is indicated 

        • Once a puppy is born- the oxytocin clock resets and you can start the protocol of oxytocin over 

    • In one study, 55% of medical management cases needed a c-section so be clear and direct with communication, frequently re-evaluated, and adapt as needed 

  • A note on financial cases: If the owners do not have the funds for the c-section, or at least most of the funds, and the dam is stable these cases can wait. In the Austin area, Safe Haven (Houston) or Emancipet are low cost options

    • Charge for medical management appropriately as these cases can take a drain on support staff 

    • Conversation goes something like this “I understand that this is a hugely unexpected cost, but unfortunately we cannot offer the c-section for under X amount. Mom is stable and even if we proceed, I am worried about the viability of the puppies. Here are some resources to have the c-section performed at another facility in the morning (because of course it’s 2AM on a Saturday). Additionally, I want to mention that if you decide not to spay her, she will most likely need another c-section in the future and you should be prepared to have an emergency fund and a scheduled c-section.”

      • This is another of those ethical things…the goal is to partner with the owner and get them to listen to you- if you are overly judgmental, they will never listen and then everyone loses 

    • These are NOT VEG Cares cases unless it is a unique circumstance (Ex: owner took in a stray dog, did take her to the vet for vaccines and a check up the week prior, came in because she was being clingy and low and behold was in active labor)