A C-section can be a stressful and chaotic nightmare, or it can be a wonderful and uplifting experience. In this article, part one of three, we will share 10 steps to become better equipped for your next C-section. Our goal is to save the offspring—and of course keep the dam safe. 1. Preparation A successful C-section requires teamwork at its best. This should include pet owners, who should be educated during any pregnancy—especially those at risk—so they know what to expect and when veterinary assistance might be needed. What is normal? What is abnormal? When might a C-section be necessary? When should they call if they think a C-section is required, so you can be ready? Many late night or early morning emergency C-sections could be avoided if more time were spent educating clients. Understanding the client’s wishes is a critical part of the discussion. Does he want the pet spayed? Can she afford another C-section? Can he properly care for another 12 puppies while working two jobs? Does the world really need more hydrocephalic Chihuahuas with the pelvis of a bumblebee? At the clinic, you and your team should be ready for a walk-in C-section at any time. For example, do you carry freshness-dated puppy and kitten milk? Use our handy checklist (see box to the right) to be prepared. Remember, you may not have any extra staff to run around during the delivery to get these items. Many seemingly little things can be done ahead of time to save time and resources when the time comes. C-section checklist An experienced team will gather as many supplies as possible before a C-section. Here is a non-exhaustive checklist. ANESTHESIA TEAM * Paperwork (records, forms) * Complete list of pre-calculated drug dosages * Various syringes and needles * Various endotracheal tubes * Laryngoscope SURGERY TEAM * Surgical blades * Scrubbing supplies * Extra gauze squares and lap sponges * Sterile towels * Suction (machine, hose and tip) Warm irrigation fluids * Towels on the floor to help cleaning up * Suture material * Retractor NURSING TEAM * Neonatal stethoscope * Neonate sized mask attached to small Ambu bag * Heating pads * Oxygen source for babies * Bulb syringes or "snot sucker” * Extra sterile hemostats (1 or 2 per neonate), suture and needle holder to tie off umbilicus * Comfy box or laundry basket for the newborns * Warm towels For example, starting to clip the abdomen on a patient who is awake will save anesthesia time. To keep the mother calm, engage the help of the owner if needed, suggests Melissa Goodman, DVM, board-qualified in the American College of Theriogenologists at Veterinary Reproductive Services in West Chester, Pa. 2. Stabilize Depending on how vigilant the owner has been, C-section candidates may present in various states of dehydration, exhaustion, hypotension, hypothermia or hypocalcemia. Clinical and biochemical abnormalities need to be addressed quickly before proceeding to safe anesthesia and surgery. Hypotension, as well as acid-base and electrolyte imbalances, should be corrected before surgery and continued postop for as long as required. Fluid therapy and temperature regulation should be at the top of your mental checklist as soon as the patient arrives. 3. Staffing In a perfect world, you would have three teams: a surgery team, an anesthesia team and a team of "baby resuscitators.” A surgical assistant can be very helpful, especially to avoid tears when the uterus is very large, Dr. Goodman suggests. A dedicated anesthesia technician is critical. Depending on the size of your team, one person should be responsible for one to three babies (puppies or kittens). Staff members should be knowledgeable and skilled in a situation where the babies will sometimes need a huge amount of care, including stimulation, warming up and airway clearance … all simultaneously. The larger the number of neonates, the more care is involved, and the more staff members are needed. An emergency C-section is not the ideal time to be teaching teammates in great detail how to resuscitate babies. However, inviting them to the OR to grab warm towels and other items will progressively teach them how to proceed and expose them to the fast-paced environment so they are prepared for the next one. 4. Analgesia Analgesia of a C-section patient is almost the polar opposite of everything we typically strive to do for other patients. Here, less is more. If the goal is to save the babies, then pre-emptive analgesia may be harmful. Margret Casal, DrMedVet, Ph.D., of the University of Pennsylvania School of Veterinary Medicine, recommends skipping premedication. Secrets to a happy C-section * Be prepared and work quickly. Preparation and speed count. * Correct hypotension and any acid-base and electrolyte imbalances. * Create two or three teams: surgery/anesthesia and "baby resuscitators.” * Withhold analgesia until after babies have been delivered. C-section risk factors* A large study found seven factors that negatively affect survival of canine neonates. They are: * emergency (as opposed to elective) surgery * brachycephalic breed * more than four puppies * a few puppies had a natural delivery * some puppies were malformed * xylazine was used * some puppies had difficulty breathing spontaneously or didn’t cry at birth Factors that improved the outcome included using propofol and not using halothane. An epidural is a great way to provide analgesia to pregnant veterinary patients, just as in human patients. But consider epidurals only if you are very quick at performing them. Pregnant patients have distended epidural veins and, therefore, a smaller epidural space, so smaller doses are needed. Line blocks are another cheap and simple way to provide local analgesia. Although local blocks may be controversial as far as pain scoring is concerned, our goal here is to keep anesthetic gas as low as possible until the neonates have been delivered. As wonderful as constant rate infusions are for analgesia, they are not ideal for C-sections, because they can depress the babies. "A reasonable compromise may be to withhold an injectable opioid until after all babies have been delivered,” suggests Dr. Casal. Conclusion The key to a successful C-section is to have the staff, the OR, the instruments and the equipment ready ahead of time. This will ensure a safe, quick and happy surgery, which we will discuss in our next installment. 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. <HOME> FOOTNOTE * Paula Moon et al. "Perioperative risk factors for puppies delivered by cesarean section in the United States and Canada.” JAAHA 2000, Vol 36, N. 4, p. 359-368. 9/23/2013 10:19 AM
