decision making in Caesarean section

Re: decision making in Caesarean section

Joyce Whitehead — Wed, 27 Jul 2011 16:25:43 GMT

[quote user="Alasdair Hotston Moore"]how much weighting do you place on owners' wishes: can this be the primary factor in the decision?[/quote]

I mainly would consider the owners' wishes in terms of finance, but most can be influenced more by me than I can by them I think.

[quote user="Alasdair Hotston Moore"]will you do CS routinely on some breeds (examples appreciated, and how do you time the surgery)[/quote]

No - in my first job many years ago we had a bulldog breeder who had elective caesers on all his bitches - the boss of the practice was fine with this and we did them when he phoned up to say they were in labour! I have done one on a French Bulldog who had 11 pups, and was so enormous I thought there was no chance of natural delivery, and the owner was keen to get them out quickly, and we again waited for signs of bedmaking, and an open cervix.

[quote user="Alasdair Hotston Moore"]how long after mating do you assume primary inertia has occured if no signs of labour have developed[/quote]

As previous posters have said, monitoring temperature and cervix is most reliable I find.

[quote user="Alasdair Hotston Moore"]if you treat for uterine inertia (with oxytocin/calcium/glucose etc), how long do you wait for progress before picking up the knife?[/quote]

If no response to 2 doses oxytocin approximately 45 mins apart.

[quote user="Alasdair Hotston Moore"]do you screen with US (or another way?) for fetal distress[/quote]

No, not good enough scanner or operator.

[quote user="Alasdair Hotston Moore"]once a Caeser, always a Caeser? (and let's try not to get into the ethics for this purpose...or go on then...)[/quote]

No, just careful monitoring. If a caeser for inertia or difficult to get some out, especially if lot of incisions, then I strongly advise not breeding again. Having said that, I have had 2 caesers, one emergency, one elective, and could have had a third if I had wanted another child (foetal oversize in my case).

[quote user="Alasdair Hotston Moore"]would you sometimes, ofen or always advise concurrent neutering[/quote]

Not that often, most of our whelpings are deliberate matings by mostly responsible breeders.

[quote user="Alasdair Hotston Moore"]practically, how much assistance do you need to arrange (if this would affect your decision making)[/quote]

I would be very unwilling to manage with less than 3 people (one operating, one on anaesthetic, one on pups). Fortunately husband a vet too, so often have 2 vets and a nurse, and if out of hours, we have 2 teenagers who have been reviving pups for some years and are usually happy to help!

Re: decision making in Caesarean section

Martin Atkinson — Wed, 27 Jul 2011 11:46:53 GMT

[quote user="alex gough"]

Do you have the option to phone a friend? ;)

Alex

[/quote]

I find 'ask the audience' better, the nurses generally have the most common sense!

Re: decision making in Caesarean section

Alex Gough — Wed, 27 Jul 2011 10:47:43 GMT

Do you have the option to phone a friend? ;)

Alex

Re: decision making in Caesarean section

Martin Atkinson — Wed, 27 Jul 2011 09:25:59 GMT

[quote user="David Mills"]

[quote user="Mark Holmes"]I have heard of a technique whereby you clamp the ovarian Pericles and cervix and lift out the uterus enbloc to have the pups delivered by another party (I assume a vet) while the bitch is closed. Never tried it has anybody else? We charge standard fee regardless of the fate of the uterus.

[/quote]

Yes, works really well. Much, much cleaner. Quicker deliveries, less kit required, shorter surgical time. Top tip is to clamp above the ovary first, whilst removing the uterus then go back after and trim away.

[/quote]

Eek sounds scary. I assume the client wants the bitch spayed and has given consent for this procedure first. Sounds like too much risk of clamp slip and haemmorhage for my liking. What would the VDS/RCVS say if it went belly up and the client complained?

Re: decision making in Caesarean section

Rob Reid — Wed, 27 Jul 2011 09:24:17 GMT

[quote user="David Mills"]Yes, works really well. Much, much cleaner. Quicker deliveries, less kit required, shorter surgical time. Top tip is to clamp above the ovary first, whilst removing the uterus then go back after and trim away.[/quote]

I too use this method when concurrently neutering - works well, quick and clean. I tend to just clamp as I would do for a normal spey rather than above the ovary - I find the ovaries easy enough to exteriorise as long as your incision is long enough.

Re: decision making in Caesarean section

David Mills — Wed, 27 Jul 2011 01:01:20 GMT

[/quote]

Re: decision making in Caesarean section

Mark Holmes — Tue, 26 Jul 2011 22:43:33 GMT

I have heard of a technique whereby you clamp the ovarian Pericles and cervix and lift out the uterus enbloc to have the pups delivered by another party (I assume a vet) while the bitch is closed. Never tried it has anybody else? We charge standard fee regardless of the fate of the uterus.

Re: decision making in Caesarean section

Clive Ansell — Tue, 26 Jul 2011 22:34:31 GMT

Steve - all the practices I have ever worked charge a supplement to spey at the same time, usually about 50% of routine spey price. You're idea is better though, as you say it is often quicker and certainly not much longer, and it does help to get them speyed - maybe we should discount slightly for concurrent spey?

Re: decision making in Caesarean section

Stephen Courtney — Tue, 26 Jul 2011 22:10:28 GMT

I would not want to do an elective ever - I'd wait till signs of labour/dystocia were evident.

My vague rule of thumb is if unproductive straining for more than 30 minutes, a caesar is likely to be needed. If there is a bit of a pup sticking out and it isn't delivered within 20 minutes, a likely caesar again.

The greenish discharge suggests placentae are starting to detach - so time is running out. but if a delivery was proceeding normally it wouldn't bother me.

I usually reserve oxytocin for tired girlies with one or two babies left. You will never get the whole litter out manually if they have a belly full!. I always give a little IV calcium first, then the oxytocin. Seems to give better results. I have done a lot of manual whelpings on larger bitches - notably a Great Dane - and have a client who breeds GSDs that occasionally need help.

If nothing at all is happening it is much harder to decide. If the owner is sure of dates, if the cervix is open, if the temperature has dropped, then I'll probably caesar sooner than later. Cover your ass mentality - be seen to do 'everything you could' coupled with a healthy dollop of self interest - operate sooner than later - you're more awake, bitch and pups are less knackered, and the success rate goes up.

Caesars are pretty costly at our hospital, especially if OOH, but the whelping charge per hour is too. I'm very wary of sitting around tickling a dog with oxytocin while the night progresses, prefer to get in and out asap. And i prefer to spay if at all possible - it's actually quicker than sewing the uterus up again properly.

As an aside, do other vets charge a bigger fee to spay at the end of the caesar? I'm not sure what to do. i feel as i can finish quicker if i do spay, and I don't want to discourage the owner, I charge the same. I have seen some vets add a spay fee on top. What's the norm?

Re: decision making in Caesarean section

Rob Loxley — Tue, 26 Jul 2011 17:49:38 GMT

[quote user="Alasdair Hotston Moore"]how much weighting do you place on owners' wishes[/quote]

In private practice this does come into it, especially when it's not cut-and-dried. What drives their wishes may be finances (especially if they have none or if it's coming up to being OOH), previous experience (good or bad with CS or with not), practicalities etc. I think if you get into conflict with the owners you better have all the Is dotted and Ts crossed in case it doesn't go to plan.

[quote user="Alasdair Hotston Moore"]will you do CS routinely on some breeds[/quote]

We don't have any clients we currently do this for, though we have some breeds that often need CS (the pugs spring to mind).

[quote user="Alasdair Hotston Moore"]if you treat for uterine inertia (with oxytocin/calcium/glucose etc), how long do you wait for progress before picking up the knife?[/quote]

20-30mins after oxytocin, sometimes repeat. Generally will inject then leave the dog in a quiet kennel while we go set up for surgery...

[quote user="Alasdair Hotston Moore"]do you screen with US (or another way?) for fetal distress[/quote]

I find the ultrasound very useful for seeing what's going on with the pups, it can be a good tool to push for CS or to keep me happy that watchful waiting is sensible.

[quote user="Alasdair Hotston Moore"]would you sometimes, ofen or always advise concurrent neutering[/quote]

Will always discuss it, for 'pets' the uptake is higher than 'breeding' bitches!

[quote user="Alasdair Hotston Moore"]practically, how much assistance do you need to arrange (if this would affect your decision making)[/quote]

This is a factor, particularly if it's coming to the end of the day and staff will be leaving if we prevaricate too much! Have done CS from having another vet and a raft of nurses, to just one nurse in the middle of the night (watching the GA and seeing to the pups) and have done it with no qualified assistants (but never the owner before you ask) so having to talk everyone through it all...

I believe the VDS still strongly advise against having the owner present, and I am strict on that (cite elf-and-safety if need be)

Re: decision making in Caesarean section

Rob Reid — Tue, 26 Jul 2011 16:50:36 GMT

[quote user="Alasdair Hotston Moore"]how much weighting do you place on owners' wishes: can this be the primary factor in the decision?[/quote]

I consider the owners wishes and of course their circumstances as well. The primary factor in the decision should always be a clinical one if possible, but finances, emotions, practicalities and capabilities of the owner all play a role as such as well.

[quote user="Alasdair Hotston Moore"]will you do CS routinely on some breeds (examples appreciated, and how do you time the surgery)[/quote]

No, I try and let nature take it's course. I think elective CS is potentially a dangerous thing timing-wise - opening yourself up to all manner of legal problems. Best to wait for things to start themselves and judge the situation as appropriate....

[quote user="Alasdair Hotston Moore"]

how long after mating do you assume primary inertia has occured if no signs of labour have developed?

[/quote]

Theory states that you should assume this 36hrs after rectal temperature drops below 99degrees. In practice this can be difficult to calculate as not all owners are good at keeping a check on their bitches temperature, so I will tend to consider other factors such as accuracy of mating dates, owners observations and examination fidnings as well before assuming primary inertia is present. In terms of days post mating I would say 70 days plus (I have seen a Dachshund whelp on day 72 though...)

[quote user="Alasdair Hotston Moore"]

if you treat for uterine inertia (with oxytocin/calcium/glucose etc), how long do you wait for progress before picking up the knife?

[/quote]

Ideally I would inject, wait 1 hour then give a second injection and wait a further 30-45 minutes before intervening. In practice though, time of day and availability of staff etc. becomes an issue so this would not always happen.

[quote user="Alasdair Hotston Moore"]do you screen with US (or another way?) for fetal distress[/quote]

No, I am not clever enough with the ultrasound for this!

[quote user="Alasdair Hotston Moore"]

once a Caeser, always a Caeser? (and let's try not to get into the ethics for this purpose...or go on then...)

[/quote]

Not necessarily.....but I would be lying if I said that a decision to operate wasn't influenced in some way by a bitch having had a previous CS!

[quote user="Alasdair Hotston Moore"]would you sometimes, ofen or always advise concurrent neutering[/quote]

I would always advise this. The majority of breeders aren't happy about it, but I do actively try and encourage it.

[quote user="Alasdair Hotston Moore"]practically, how much assistance do you need to arrange (if this would affect your decision making)[/quote]

At least 2 other nurses, 1 for the anaesthetic and at least 1 to bring pups round. Preferably more if a big litter! I never let owners help - asking for trouble there. And as stated earlier the presence (or absence) of appropriate levels of staff may have a bearing on the decision to operate.

Hope this helps!

Re: decision making in Caesarean section

Michael Woodhouse — Tue, 26 Jul 2011 16:37:48 GMT

[quote user="Martin Atkinson"]Any green discharge is an indication for an emergency CS.[/quote]

Is it? I was under the impression that green discharges were normal release of red blood cell breakdown products (IIRC biliverdin or bilirubin) accumulated in the puppies zonary placenta? So long as it doesn't smell bad I don't worry at all.

Re: decision making in Caesarean section

Thomas Johnson — Tue, 26 Jul 2011 16:33:44 GMT

how much weighting do you place on owners' wishes: can this be the primary factor in the decision?

Very little, though if the owners want a caesarian and things aren't going smoothly I might do one sooner than otherwise. If they don't want one and I think the bitch needs one they don't get much choice.

will you do CS routinely on some breeds (examples appreciated, and how do you time the surgery)

I've not worked in a practice with any breeder clients of breeds such as bulldogs, but I think it's unlikely that I would.

how long after mating do you assume primary inertia has occured if no signs of labour have developed

I would normally wait until day 68 after mating, but if the bitch has had previous litters and always had the pups on day 63 I would be more likely to act sooner. I would probably be seeing them daily to check for their temperature dropping, and the cervix opening.

if you treat for uterine inertia (with oxytocin/calcium/glucose etc), how long do you wait for progress before picking up the knife?

I normally give Oxytocin and wait 20 minutes, if no sign of activity then a second injection, if still nothing after half an hour then caesarian, and no further oxytocin injections if things stop again.

do you screen with US (or another way?) for fetal distress

No, but I will use ultrasound if the bitch has delivered several pups and I'm not sure if there are any remaining.

once a Caeser, always a Caeser? (and let's try not to get into the ethics for this purpose...or go on then...)

No, but I would probably make the decision to caesar quicker if the bitch has had one previously.

would you sometimes, ofen or always advise concurrent neutering

Always offer, and strongly recommend unless planning to breed again, and no medical reason why they shouldn't breed again.

practically, how much assistance do you need to arrange (if this would affect your decision making)

Can manage with one nurse, two is better. Will pass pups through to the owner in another room if necessary, but won't have them in theatre.

Re: decision making in Caesarean section

Martin Atkinson — Tue, 26 Jul 2011 15:35:04 GMT

[quote user="Alasdair Hotston Moore"]

Dear colleagues, I would be interested in a second or 10 or your time! I am giving a short lecture on WHEN to perform a CS at BSAVA congress and it would be interesting to hear from you on what criteria you use. Assuming I get enough replies to make some useful contribution, I promise in return to summarise them for the forum. The poll function does not seem to offer what I need or give you much option in response so please instead reply to this thread or e-mail me at ahm@e-vet.com

Be free to consider none or all of my suggestions below in your reply

You might include your thoughts on:

how much weighting do you place on owners' wishes: can this be the primary factor in the decision?

None, I'm the vet, I hate profesional breeders so I hope they go somewhere else, hobby breeders generally know nothing, it is on a clincial decision.

will you do CS routinely on some breeds (examples appreciated, and how do you time the surgery)

This should not be necessary should it? But when I did have a bulldog breeder they were almost routine.

how long after mating do you assume primary inertia has occured if no signs of labour have developed

How likely is it that a bitch would not show some signs of first stages of labour, i.e. nest making and how often is it lack of owner observation? - they always have in my experience so i would consider CS if no progression from that in 24 hrs. If there was genuinely none: once temperature has fallen below 100F for more than 24hrs or has started to rise again. I'm unlikely to worry in less than 5 days over predicted whelping date calculated from mating date if the bitch is clinically well. Any green discharge is an indication for an emergency CS.

if you treat for uterine inertia (with oxytocin/calcium/glucose etc), how long do you wait for progress before picking up the knife?

I'd allow 20 for a first injection of oxytocin to work, repeat with a larger dose and then reach for the knife if still no response after a further 20 minutes. Calcium is a bit different, it's never been an issue IME but I guess I'd want to wait at least until Ca levels were corrected on test.

do you screen with US (or another way?) for fetal distress

Have only had functional ultrasound once at the right time and it was reassuring to see the little critters moving and their hearts beating but I wouldn't feel confident in assessing foetal distress. If I can palpate foetal movement I consider that a good sign.

once a Caeser, always a Caeser? (and let's try not to get into the ethics for this purpose...or go on then...)

Bulldogs yes, other breeds give 'em a chance

would you sometimes, ofen or always advise concurrent neutering

In the case of irresponsible owner I may but having had one bitch bleed to death I'm once bitten twice shy on this one.

practically, how much assistance do you need to arrange (if this would affect your decision making)

I've made do with one nurse and would proceed with that, ideally 2 and if the breeder was sensible I may involve them but I would have to desperate.

[/quote]

One major factor in deciding rather cynically is time of day, if it is getting late and it is looking unlikely that the bitch is going to whelp I may go ahead earlier that if it was earlier in the day with more help, everyone less tired etc. I feel a caesarian performed almost electively this way is going to have a much higher chance of succcess than waiting and risking foetal distress and a poorer recovery with the bitch when conditions are not ideal. In cases of possible secondary uterine inertia, where there there is a long pause after one or more pups I wouldn't panic these days (used to) so long as there isnt any unusual discharge and the bitch is clinically well and not exhausted from straining.

Hope this helps

Martin

Re: decision making in Caesarean section

Mark Holmes — Tue, 26 Jul 2011 15:32:32 GMT

[quote user="Alasdair Hotston Moore"]

how much weighting do you place on owners' wishes: can this be the primary factor in the decision?

[/quote]

I did not cover this question. Yes I place weight on the owners wishes in that the fate of the puppies can vary in significance.

With some dogs the pups are of significant value, not just financial but more importantly emotional value to the owner, in other circumstances they are of less. Compare the family lab with the working collie for example. The life of the bitch is rarely at risk in the short term and if the fate of the pups is less important one may be tempted to wait longer than if the pups are of significant value (of what ever sort)

A little brutal but thats nature.

Re: decision making in Caesarean section

Clive Ansell — Tue, 26 Jul 2011 13:52:11 GMT

[quote user="Alasdair Hotston Moore"]

how much weighting do you place on owners' wishes: can this be the primary factor in the decision?

[/quote]

As a locum it depends where I am working. In a private practice with a breeder client for example I am more likely to go along with what they want, as I've no wish to be on the end of a lawsuit (with no support from colleagues) for not doing so, that said the decision would be primarily a clinical one. At 2 charity clinics I work the decision is 100% a clinical one, the clients wishes are not considered at all (if they don't like it, the doors over there approach)

[quote user="Alasdair Hotston Moore"]

will you do CS routinely on some breeds (examples appreciated, and how do you time the surgery)

[/quote]

rarely, but it is a factor in the decision making process. A bulldog or SBT that has had 3 CS before and not proceeding is very likely to need it again. I don't do elective CS's, always wait until signs of labour.

[quote user="Alasdair Hotston Moore"]

do you screen with US (or another way?) for fetal distress

[/quote]

very rarely.

[quote user="Alasdair Hotston Moore"]

once a Caeser, always a Caeser? (and let's try not to get into the ethics for this purpose...or go on then...)

[/quote]

No, I have seen bitches whelp that have had CS before, but again if they have had previous CS, more likely to need one again.

[quote user="Alasdair Hotston Moore"]

would you sometimes, ofen or always advise concurrent neutering

[/quote]

Always strongly advise and offer it (I've had breeders' not like it, but tough). compulsory, no option given and consent obtained for speying in the 2 charity clinics I work. Should be enforced much more by the profession I believe, certainly with hideously deformed breeds such as the Bulldog and SharPei.

[quote user="Alasdair Hotston Moore"]

practically, how much assistance do you need to arrange (if this would affect your decision making)

[/quote]

One preferably two nurses, or one nurse and another helper. Never allow owners or clients to help in theatre, may pass puppies through to reception so they can revive. Major surgery is not a spectator sport.

Re: decision making in Caesarean section

Michael Woodhouse — Tue, 26 Jul 2011 12:37:36 GMT

[quote user="Alasdair Hotston Moore"]how much weighting do you place on owners' wishes: can this be the primary factor in the decision?[/quote]

Very little!

[quote user="Alasdair Hotston Moore"]will you do CS routinely on some breeds (examples appreciated, and how do you time the surgery)[/quote]

No, think it's an awful thing in any species.

[quote user="Alasdair Hotston Moore"]if you treat for uterine inertia (with oxytocin/calcium/glucose etc), how long do you wait for progress before picking up the knife?[/quote]

Depends on how things are progressing. My personal rule is no more than 2 oxytocin injections an hour apart and then give an hour after the second. If nothing has happened then it usually won't.

[quote user="Alasdair Hotston Moore"]do you screen with US (or another way?) for fetal distress[/quote]

No - our cow rectal scanner not ideal for such!

[quote user="Alasdair Hotston Moore"]once a Caeser, always a Caeser? (and let's try not to get into the ethics for this purpose...or go on then...)[/quote]

No, I have had litters of live puppies born after a previous caeser elsewhere.

[quote user="Alasdair Hotston Moore"]would you sometimes, ofen or always advise concurrent neutering[/quote]

Always offer, 50:50 uptake I would say. The spay is quite easy but those blood vessels are scary!

[quote user="Alasdair Hotston Moore"]practically, how much assistance do you need to arrange (if this would affect your decision making)[/quote]

That can be an issue, especially in the middle of the night. I like 2 assistants, but will use the owner if sensible.

My personal thought is a lot of vets rush and do a lot of caesarians. The vast majority of births will happen as nature intended whether it's a dog, cow or sheep. Was talking to a qualified vet recently who had never used a pair of whelping forceps or a vectis, but has done more bitch ceasers than I had. I have a feeling many of the old skills have been lost.

Re: decision making in Caesarean section

Mark Holmes — Tue, 26 Jul 2011 12:07:26 GMT

I generally tend to go for a caesar quickly, particularly if they have a belly full and have not yet passed a pup. Primary inertia is relatively common, particularly with a large litter (last one had 13) and the pups and bitch are always much stronger if you haven't messed about for an age. I will use oxytocin if the majority of the litter is passed and there is only the odd one stuck, which is not that common in my experience.

I will diagnose primary inertia if the temperature has dropped the birth canal is open, there has been no sign of a pup for 36hours and the dates are about right. It is always a bit of a call though.

I caesar/spay when possible and always offer it.

Is it bad to say that knowing I can have a caesar done and dusted in 45minutes and all pups and bitch recovering is a factor too.

Assistance - generally 1-2nurses (I have had the odd owner help if really stuck)