Caesarian analgesia

RE: Caesarian analgesia

Gillian Mostyn — Sun, 18 Mar 2018 12:05:37 GMT

[quote user="Christina Smith"]I see my bitch spays back after 48 hours. The majority come in leaping around wagging their tails,unconcerned about palpation of abdomen/wound. [/quote]

Absolutely. But if, as I assume, they are discharged within hours of the surgery, who is carrying out pain scoring for the next 42 hours? How accurate do you think that is, considering most owners correctly assume a quiet, subdued animal is normal post-op?

RE: Caesarian analgesia

Christina Smith — Sun, 18 Mar 2018 11:30:26 GMT

Of course abdominal surgery is not painless. Second question is much more difficult to answer and I don't know. I imagine it is dependant on the reasons for surgery and the procedure. Interestingly my sister recently underwent bowel surgery via laproscopy. She was given remifentanil, paracetemol and dexamethasone IV intra -op. I think the medics are very concerned re opioid hyperalgesia and slower recoveries. Her post-op pain relief was paracetemol/codeine orally. She describes spasms of pain especially related to eating. After 48 hours she defecated and all was well. The animals that I have operated on for small intestinal obstructions have markedly lower pain scores post-op than pre-op. I expect to see them eating and defecating within 48 hours. I see my bitch spays back after 48 hours. The majority come in leaping around wagging their tails,unconcerned about palpation of abdomen/wound. Advice usually on how to prevent them from jumping. Even those that have some seroma formation. The ones that are sensitive usually have some degree of clipper rash or inflammation of the skin around the wound. I see more post-operative pain percentage-wise in the dog castrates and have lately stopped clipping scrotal hair.I do give out meloxicam to all neuters. I will in future prescribe pardale V for my bitch caesarians. [quote user="Gillian Mostyn"]

[quote user="Christina Smith"]Pain scoring is definitely worthwhile. I find the concept of hidden pain difficult especially in cats and dogs. [/quote]

OK...looking at it another way, do you think it is possible to carry out abdominal surgery painlessly? How long would you anticipate the pain of surgery to persist post-operatively? (In any mammal.)

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RE: Caesarian analgesia

Gillian Mostyn — Sun, 18 Mar 2018 09:12:12 GMT

[quote user="Christina Smith"]Pain scoring is definitely worthwhile. I find the concept of hidden pain difficult especially in cats and dogs. [/quote]

OK...looking at it another way, do you think it is possible to carry out abdominal surgery painlessly? How long would you anticipate the pain of surgery to persist post-operatively? (In any mammal.)

RE: Caesarian analgesia

Christina Smith — Sun, 18 Mar 2018 07:51:29 GMT

Pain scoring is definitely worthwhile. I find the concept of hidden pain difficult especially in cats and dogs. Even chronic pain is discernible in the way they interact. Pinpointing pain is crucial for diagnostic purposes and thank goodness they do show it. The small herbivores I concede are much more difficult.

RE: Caesarian analgesia

Gillian Mostyn — Sat, 17 Mar 2018 21:13:34 GMT

Like others, I thought that not giving good and ongoing analgesia after abdominal surgery was an antiquated idea. Apparently not. But I always put this down to the ' a bit of pain keeps them quiet' argument. But that someone thinks that it isn't actually painful anyway..... astounding.

RE: Caesarian analgesia

David Mills — Sat, 17 Mar 2018 20:40:10 GMT

[quote user="Christina Smith"]

Distraught is a bitch that can't settle with her pups. I haven't had that problem post caesarian. If she shows signs of distress then I would reach for pardale V. The end of a pregnancy is a relief IMO.

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Have you considered that the hormonal drive in dogs (or cats) to protect their young may overarch any pain from that?

It's a bit like mothers love. There are some interesting studies that this "love" an allow mothers to walk (for a short time) on broken limbs to protect their young which they otherwise couldn't do.

Just because an animal does something doesn't mean we can't help reduce the suffering in that. A cat with a broken pelvis will often drag itself home. In your logic because it can move, no need for pain relief.

I have no hesitation in saying that your understanding of welfare and your personal ethics are, on this evidence, abominable.

RE: Caesarian analgesia

Gillian Mostyn — Sat, 17 Mar 2018 20:34:44 GMT

Have you had a caesarian? Any abdominal surgery at all?

RE: Caesarian analgesia

Christina Smith — Sat, 17 Mar 2018 20:01:02 GMT

RE: Caesarian analgesia

David Mills — Sat, 17 Mar 2018 18:37:38 GMT

[quote user="Michael Woodhouse"]Forgive my candid reply, but that disgusts me[/quote]

Yep, agree.

It's a similar nonsense to "oh he doesn't need a dental cos he's still eating" and "pain is nature's splint" (as if we can completely eradicate pain in an animal post-surgery).

Didn't know such archaic barbaric opinions existed. Shocked.

RE: Caesarian analgesia

Joyce Whitehead — Sat, 17 Mar 2018 17:57:19 GMT

I must agree with Michael here. Having had two caesarians myself (v large babies versus not so large pelvis) I certainly needed pain relief. In my case I had intra epidural opioids first time, and IV opioids second time, both for 24 Hours, then was weaned on to paracetomol (and I think cocodamol before that). Believe me, the experience was not without pain!

We also tend tend to send home with pardale these days although I’ve also used carprofen in the past.

RE: Caesarian analgesia

Michael Woodhouse — Sat, 17 Mar 2018 16:22:21 GMT

[quote user="Christina Smith"]I would avoid pain relief unless the bitch is rejecting or not feeding. [/quote]

Forgive my candid reply, but that disgusts me. That would be a wholly unacceptable attitude to small animal analgesia in surgery, and a view held by the profession 30 years ago when a bit of pain stopped them doing too much.

We KNOW paracetamol safe in pregnant women. We KNOW paracetamol safe in children as young as 2 months as age, available OTC. The testing and numbers involved eclipse any veterinary information we have on this.

I seriously implore you to reconsider this in your practice. Horrified.

RE: Caesarian analgesia

Richard Carter — Sat, 17 Mar 2018 13:48:50 GMT

and just remember if aspirin was launched today, it wouldn't get a licence due to considerable life threatening side effects... lucky then for those millions who have benefited from 'grandfather' clauses.

then there is thalidamide launched as a treatment for 'morning sickness'

RE: Caesarian analgesia

Alistair Graham-Evans — Sat, 17 Mar 2018 03:03:37 GMT

[quote user="Christina Smith"]If paracetemol is not an NSAID then what is it ?[/quote]

It is a weak prostaglandin inhibitor ( COX3)

It has little anti-inflammatory activity

It may antagonise enzymes in the brain to modulate pyrexia and pain sensation ( by inhibiting PG synthesis )

So really mainly analgesic and anti-pyretic.

RE: Caesarian analgesia

Beats — Fri, 16 Mar 2018 20:21:55 GMT

[quote user="Thomas Johnson"]The problem with this is that paracetamol is not a NSAID[/quote]

It is if the datasheet says it is ;-)

It's not a steroid - check.

It is a drug - check.

It may be an effective anti-inflammatory in the dog* - check.

*https://www.ncbi.nlm.nih.gov/pubmed/3184254

RE: Caesarian analgesia

Anthony Todd — Fri, 16 Mar 2018 20:02:40 GMT

[quote user="Christina Smith"]Most of them in my experience just get on with it.[/quote]

Yes, in mine too.

Never had, or heard of, any bitch having anything but supportive "mothering" actions towards her pups.

Mind you they did have Acp as a premed usually....

RE: Caesarian analgesia

Christina Smith — Fri, 16 Mar 2018 17:52:58 GMT

If paracetemol is not an NSAID then what is it ? Anti-pyretic, pain relief. Surely it is anti-inflammatory and non-steroidal. A drug that can have very serious side-effects. Is it safe for puppies ? Certainly not safe for kittens. Perceived safe in human pregnancy but it's abuse leads to many fatalities. A lack of knowledge and data should not lead us away from more studied and understood drugs on blind faith in something that has not been explored. I would avoid pain relief unless the bitch is rejecting or not feeding. Most of them in my experience just get on with it. Given the relief of all that abdominal pressure and maternal hormones flooding in. Pain relief for humans is very controversial and very much subjective. Certainly avoid opiates unless you are convinced of pain. Discuss with owner. Bitches eating their puppies will always be blamed on your drug /lack of .

RE: Caesarian analgesia

Iain Richards — Fri, 16 Mar 2018 10:17:47 GMT

Carprofen does get into the milk, but in tiny tiny doses. So ideal for any homeopathic inclined folk as the pups will be protected from any GI upset.

RE: Caesarian analgesia

Michael Woodhouse — Fri, 16 Mar 2018 00:40:10 GMT

[quote user="Alistair Graham-Evans"]There is probably some level of excretion of all drugs in milk after birth; however, its not that great because of the way gap junctions between mammary gland cells work[/quote]

We know carprofen doesn't get into cows milk.....

(no milk withhold and can continue selling the milk)

I don't see why you'd use meloxicam product in this case, but then I suppose some practices woun't have injectable carprofen.

RE: Caesarian analgesia

Julie Innes — Thu, 15 Mar 2018 09:00:34 GMT

This thread is really interesting and informative. I honestly did not know that meloxicam was contraindicated in pregnancy, and have probably used at/ after C-section , So good to know!

RE: Caesarian analgesia

Alistair Graham-Evans — Thu, 15 Mar 2018 00:14:50 GMT

Notes from an email from a reproduction specialist

There is almost no research about any form of pain relief in either Caesarean or post-Caesarean
Whatever you give to the bitch you’ll give to the pups transplacentally
There is probably some level of excretion of all drugs in milk after birth; however, its not that great because of the way gap junctions between mammary gland cells work
In humans given NSAIDs with Caesar, babies get the NSAID via milk but the level in baby blood is very low and there has been no report of baby organ damage as a result
In dogs there are two relevant papers: in 2010 we wrote a review of 500 Caesars that got meloxicam after the pups were delivered and before the bitch woke up and we recorded no effects in pups of the meloxicam BUT we didn’t look specifically for pup problems and we didn’t follow them thru their lives.
we’ve designed some trails to investigate this with the UQ Vet school at the moment for methadone and also NSAIDs

I think if I was a lawyer I would be able to come up with evidence or arguments that a pup delivered by caesarean died as a result of a decision taken by the vet in 100% of cases - mine included. Basically it all comes down to trust between the client and the vet, and communication, but a litigious client who expects 100% success will attempt to demand compensation or report you to RCVS one day. I believe human obstetricians usually have several ongoing legal cases at any given time.

The drug companies absolve themselves by advising not to use their drug.

Maybe there is a case for a specific disclaimer / consent form for these operations. However it could be argued that if a drug was used that was contraindicated on the data sheet the disclaimer is not relevant legally.

I always advise the owner of the risks and explain that I will put the health of the bitch before the pups but attempt my best for a good outcome for both. I will not do an elective Caesarean without a progesterone assay and ultrasound - if they refuse permission for these I invite them to seek help elsewhere as it is obviously not an emergency.

RE: Caesarian analgesia

Lucy Fleming — Wed, 14 Mar 2018 17:22:53 GMT

[quote user="Bob Russell"]'as with other NSAI's use should be avoided in late pregnancy as it may cause premature closure of the ductus arteriosus[/quote]

Every day's a school day! I had no idea that this could happen. Anyone have any idea if this is just in humans?

RE: Caesarian analgesia

Bob Russell — Wed, 14 Mar 2018 17:08:41 GMT

Meloxidyl data sheet states 'Do not use in pregnant or lactating animals' but also 'safety and efficacy has not been established in pregnancy or lactating animals'.

Both are clear statements that it is a drug that should be used with extreme care and with an owner clearly informed.

I have used it without problems in caesarians and probably would still do so where there is no more suitable product. Lack of testing does not mean it will not work nor that it will be detrimental. It does mean that the vet is sticking his/her neck out!

The human version of meloxicam states that 'as with other NSAI's use should be avoided in late pregnancy as it may cause premature closure of the ductus arteriosus. Hardly an issue with a perioperative caesarian patient.

https://www.fda.gov/ohrms/dockets/ac/06/briefing/2006-4254b_14_05_KP%20MeloxicamFDAlabel82005.pdf

RE: Caesarian analgesia

Evelyn Barbour-Hill — Wed, 14 Mar 2018 16:33:12 GMT

[quote user="David Mills"]

What's the difference between not indicated (carprofen, pregnancy, nothing about lactation) and contraindicated (meloxicam pregnancy and lactation)?

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Not indicated means just not indicated. As in "an antibiotic is not indicated in a viral infection".

Contra-indicated means there is good reason to suppose it will be actually harmful. As in "a corticosteroid is contra-indicated in viral keratitis".

Here's another thought. The manufacturer may state "do not use in pregnant animals". But does that apply if in ten minutes time the animal won't be pregnant any more?

RE: Caesarian analgesia

Rob Davis — Wed, 14 Mar 2018 16:31:07 GMT

[quote user="Gillian Mostyn"]I don't have a fear of going off license per se... just with breeders![/quote]

Fair enough!

RE: Caesarian analgesia

Lucy Fleming — Wed, 14 Mar 2018 15:57:02 GMT

[quote user="Clive Ansell"]

If we talking about breeders and C-sections; legally.

I would take "contraindicated" as being told specifically not to use it - i.e there are indications it may not be safe or suitable. Would be difficult to defend in court without good reason.

I would take "not indicated" as being told it is advised not to use it, and you do so at your own risk and on a risk-benefit assessment basis. Off label disclaimer signature required.

[/quote]

I would tend to agree - but it's interesting that the same level of research (i.e. none) is used to justify different recommendations in different products!