September 23, 2013
While rubbing babies and clearing their airways, we also should strive to prevent the three "hypos" in neonates: hypothermia, hypotension and hypoxia.
We conclude our three-part article on C-sections with resuscitation and care of the neonates. It is time to change a few old habits and to embrace more modern techniques.
Part 1 is here; Part 2 is here.
While rubbing babies and clearing their airways, we also should strive to prevent the three "hypos” in neonates: hypothermia, hypotension and hypoxia.
Hypoxia is a constant battle during a C-section. The amniotic sac should be removed as soon as possible, and the mouth and airway must be cleared with a bulb syringe.
"Don’t use too much suction,” reminds Margret Casal, DrMedVet, PhD, Dipl. European College of Animal Reproduction, University of Pennsylvania School of Veterinary Medicine, "as it could damage the delicate tissue of the pharynx and larynx.” Alternatively, a mucus suction device for human babies can be used, e.g., the poetically called "snotsucker nasal aspirator.”
Hypothermia can be prevented by using warm towels straight out of the dryer, or a warm air or warm water blanket. Rubbing the babies’ thorax vigorously helps clear the lungs and airway of fluid, stimulates their breathing and dries them out—therefore decreasing heat loss.
Hypotension is addressed as soon as the dam arrives in the hospital. Preop IV fluids should help the mother as well as the babies. Although there is no blood pressure cuff small enough for neonates, a normal heart rate, color, movement and temperature are indirect indicators of adequate blood pressure.
It is important to examine each neonate for any obvious congenital defects: cleft palate, umbilical or inguinal hernia, anasarca (aka "water baby”).
When can you consider that a neonate is probably safe? A good rule of thumb is to resuscitate until you count 10 breaths per minute, and the baby is moving and crying.* Tie off the umbilical cord, place the neonate in a warm environment, make sure nothing blocks the airway, and move on to the next baby.
Having an ultrasound machine in the OR can quickly help determine the status of a questionable heart.
"It is generally considered that you should try to resuscitate a baby for 30 minutes before giving up,” Dr. Casal says.
Swinging neonates is a technique that many of us do—doctors and technicians. Why? Probably because we’ve learned from someone, who undoubtedly learned it from somebody else. Yet the technique has been linked to neonatal death—immediate or delayed—from a subdural hematoma or cerebral hemorrhage.
And then there’s the ultimate taboo only a few colleagues have shared in confidence: dropping a (slippery) neonate, leading to instant death.
Swinging neonates is no longer considered state-of-the-art. Think of this practice as the veterinary equivalent of the dreaded "shaken baby syndrome.”
Another possible concern of swinging is that gastric content could be forced into the pharynx because of the force of the maneuver. In turn, this could lead to aspiration.
If you follow our reproduction specialists’ advice, including skipping premedication, the babies are likely to come out of the womb much more vigorously than with your current protocol.
Remember that virtually any drug given to the mother will affect the babies.
Few drugs are effective or safe in neonates. Atropine, epinephrine and even good old doxapram have not been proven effective or safe. Neonates don’t even have receptors for these drugs. In addition, virtually all drugs used to help in resuscitating efforts of a neonate are rarely effective unless given IV.
Antibiotics are usually not necessary if sterile technique has been followed. If sterility was questionable during surgery, it is better to err on the side of caution and prescribe antibiotics.
Preoperative IV cefazolin may be given. Postop, amoxicillin or amoxicillin-clavulanic acid can be prescribed for one week. These antibiotics will end up in the dam’s milk, but they are safe for the babies.
Both our reproduction specialists consider that pain medications are rarely necessary at a time when copious endogenous endorphins are released. Tramadol can be dispensed for a few days if needed. NSAIDs are usually avoided, as they can end up in the newborns through the milk. Among other side effects, they can damage their kidneys.
* Do not swing neonates.
*Allow nursing of colostrum ASAP
* Send mother and offspring home ASAP
Unless neonates can nurse very soon, Melissa Goodman, DVM, board-qualified in the American College of Theriogenologists at Veterinary Reproductive Services in West Chester, Pa., likes to tube feed them with commercial milk.
"Bottle feeding may be fun, but it takes too much time when you have multiple neonates to take care of,” she explains. She sometimes even shows pet owners how to tube feed.
The babies can wait in an incubator until the mother is capable of taking care of them.
Once the dam is fully awake and alert, the babies can be brought to her to nurse, under close supervision.
The mother should be awake enough but not in pain in order to allow the babies to nurse. "In a dog, you have 24-36 hours after birth for babies to benefit from colostrum,” says Casal. "In a cat, you have 16-24 hours.”
Depending on the breed and the individual, the dam should be supervised closely to ensure she is taking care of her offspring appropriately. Mother and babies should be discharged from the hospital as soon as reasonable. If anesthesia went smoothly, this might be within an hour or two postop, as most dams can walk by then.
Pet owners, especially "first timers,” should be given detailed written instructions to handle feedings and general care of the neonates. Nobody will guide them besides you and Dr. Google.
Tell clients to weigh the babies daily. Each baby’s weight at birth (which should be meticulously documented at the clinic) should double within the first 10 to 14 days, explains Dr. Goodman.
Dr. Casal concurs; instructions should include simple but important advice. This includes changing bedding frequently and keeping the incision, the mammary glands and the vulva clean and dry. Warm tap water is sufficient. Puppy or kitten food is one easy option to provide proper nutrition to the mother.
* Margaret Root-Kustritz. "Clinical Canine and Feline Reproduction.” Wiley-Blackwell 2010.
** Paula Moon, et al. "Perioperative management and mortality rates of dogs undergoing cesarean section in the United States and Canada.” JAVMA 1998, Vol. 213, N. 3, p.365-369.
Overall, C-sections should be highly successful. Puppy survival rate is around 92 percent at birth, 87 percent at two hours and 80 percent at seven days.** Dams’ survival rate should be around 99 percent.**
Once mom and newborns are safe and sound, it’s time to celebrate and take pictures.
Dr. Phil Zeltzman is a mobile, board-certified surgeon in Allentown, Pa. His website is www.DrPhilZeltzman.com. He is the co-author of "Walk a Hound, Lose a Pound” (www.WalkaHound.com).
Kelly Serfas, a certified veterinary technician in Bethlehem, Pa., contributed to this article.
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