Did My Vet Miss a Puppy During My Dog’s C-Section?
“My English bulldog gave birth by c-section. The ultrasound showed 4 puppies. A different vet performed the c-section and said there were only 3 in there. One was born with an umbilical hernia that began bleeding. He was rushed to the ER vet and they said his intestines were coming through and he would likely not survive the surgery, so we had to put him down. The same night another puppy died mysteriously.
The remaining puppy is doing well now, but my dog, after birthing, has passed/expelled a lot of abnormal discharge. I didn’t know anything was abnormal until I examined and found puppy claws and fur in the discharge. It started approximately 3 weeks after the c-section. This continued with more pieces coming out each day. More claws and eventually the spine and ribs of a deceased puppy.
What happened? It’s obvious to me the vet left one inside. If it was stillborn and wasn’t removed, is this what would happen? Is it possible she just forgot one and it eventually died and decomposed?
My dog seems ok, she is eating, using the bathroom, normal temp, etc. I can’t help but think the vet was grossly negligent and possibly why we have had so many issues.” —Aimee
It is possible that your dog was in labor for too long before the puppies were removed by c-section, which would account for the death of the second puppy. In veterinary medicine, we do not have the same protocols for decision delivery interval (DDI) that are used in human medicine (1) and sometimes surgeries and anesthetic times are too long and some puppies do die.
I realize it is very hard to accept, but compare how much you paid for your own dogs c-section to what a woman pays when she goes into the hospital and has the same procedure done (often about $20,000 to $50,000). The lower cost means that there is not usually a team of obstetric nurses to take care of each puppy as they are born, nor is there an anesthesiologist for each surgery.
As far as the discharge you described, it is hard for me to say for sure, but it is definitely possible that a puppy was left in the uterus when it was checked. I cannot be sure if both horns of the uterus were taken out of the body at the same time, but if not, the lost puppy may have slipped back into the other side while the veterinarian was opening up the other side. (2)
It is also possible that the puppy was small and lodged lower down in the uterus and was not found during the surgery, but there are no statistics available on how long it would take for the fetus to break up and pass.
Sometimes, the fetus will mummify and remain inside the dog, possibly causing the female to become infertile later on. (3) If your dog has passed the fetus, the prognosis is much better than it would be otherwise, but she may still require antibiotics to help clean out the uterus.
Some Breeds Cannot Give Birth Naturally
“Breeders of brachycephalic breeds of dogs with flat faces and short noses, like Bulldogs and Boston Terriers, should be prepared to have their litter of pups delivered by cesarean,” says Dr. Croom. “Some believe that the risk for a vaginal delivery for these dogs is too high and automatically plan ahead with their vet.”
These breeds have problems with natural birth is due to their physical structure, including a very narrow pelvis and broad head, that makes it unlikely they can give birth without a C-section. Typical breeds with this problem are Boston Terriers, English Bulldogs, French Bulldogs, Pekingese, and Chihuahuas. Some larger breeds may also have a higher incidence of C-sections, including Mastiffs, German Wirehaired Pointers, and Saint Bernards.
When a C-section is performed on an emergency basis, this increases the risk for the mother, who will already likely be compromised by exhaustion, internal bleeding, dehydration, or even shock. With any surgery, there are risks to the dog from going under anesthesia, as well as the possibility of contracting infections or internal bleeding. There can also be some risk to the puppies which can be injured or die during the surgical process, though they may be at greater risk by not doing a C-section.
For breeds that need a C-section to give birth safely, these are usually scheduled 62 to 63 days after ovulation. If youre unsure about the ovulation or conception date, Dr. Croom advises that your veterinarian, “Can plan the C-section using various counting methods, 1) measuring luteinizing hormone (LH), 2) measuring progesterone levels, and 3) morphology (shape) of vaginal cells.
All require the vet to take blood for accuracy, although there are no absolutes with pregnancy!” If your veterinarian does progesterone testing, they will be looking for a reading of 3 ng/dl or under. This type of testing can happen daily with results between 3 and 4 ng/ml for a few days prior to a safe surgery date.
Dr. Croom reports, “How long it takes for a dog to recover physically from a C-section depends on her health and immunity. Another factor is the toll her body may have taken from the 63 days of being a puppy assembly factory.” The mother dog will need to recover from anesthesia, which can take between two and six hours post surgery.
The puppies will also need to be cared for while she is recovering and they cannot be left with her without supervision. A mother that is still groggy from anesthesia and exhaustion can unintentionally crush the puppies with her body weight. Your veterinary team will closely monitor both mom and puppies to make sure theyre thriving before sending them home.
Once your mother dog is home with you and the puppies, your veterinarian may have you place her on a restrictive diet for the first day to prevent vomiting. They may also provide you with a puppy milk formula and bottles, if theres a chance the dam will not be able to nurse them right away.
Because a C-section requires a large abdominal incision, youll need to care for your new mom as you would after any surgery, which means limited activity and close attention to any post-op medications. Dr. Croom reports in her experience, “Within 3 weeks, she should be totally healed, and ready to focus on weaning those pups.”
Gestion d’une hémorragie péri-partum sévère à la suite d’une césarienne chez une chienne. Ce rapport décrit la gestion intensive de la pression sanguine et des transfusions lors d’une hémorragie intra-utérine péri-partum à la suite d’une césarienne chez une chienne. L’impact des changements physiologiques associés à la gestation et à l’anesthésie sur les paramètres hémodynamiques ainsi que des techniques de gestion alternatives sont discutés.
The treatment of hypotension in this case required multiple factors to be considered simultaneously. The initial evaluation of the patient before anesthesia suggested presence of mild dehydration, likely due to the dog not eating or drinking normally during the prolonged parturition. One immediate factor which may have been responsible for the hypotension was the use of a lumbosacral epidural anesthetic. Local anaesthetics administered epidurally, alone or combined with an opioid, can cause hypotension by blockade of sympathetic response (14–16). However, epidurals with local anaesthetics limited to the abdominal region cause less hypotension compared to high thoracic epidurals, which also affect sympathetic innervation to the heart leading to decreased heart rate and contractility (16). Interestingly, in the event of PPH in humans, neuraxial analgesia is often recommended (using a rapid acting local anesthetic such as lidocaine) (17). The benefit of local anesthetic boluses through an epidural catheter is the ability to avoid general anesthesia. However, when blood loss is severe (> 1000 mL, approximately > 15 mL/kg BW) neuraxial techniques are to be implemented with caution. The approach to blood loss in the presence of neuraxial analgesia emphasizes preparedness; placement of appropriate cannulas (ideally, 2 large-bore), use of IVFT, vasopressors/inotropes, and considering early implementation of direct arterial blood pressure monitoring (17). In the reported case, despite the administration of several isotonic crystalloid fluid boluses, there was no improvement in the MAP. Given this lack of response, there was the suspicion that this patient was non-fluid responsive, and as a result the authors proceeded to vasopressor and inotropic therapies early on in the anesthetic procedure.
Peripartum hemorrhage is better described in cattle and horses. In large animals the hemorrhage is generally secondary to trauma associated with calving or foaling, with lacerations occurring in the uterus, cervix, or vagina (7). The most common cause of hemorrhage is rupture of the uterine artery within the broad ligament causing a hematoma or potential hemoabdomen. In horses, PPH accounts for 40% of all periparturient deaths in mares (8). The literature in large animals describes conservative (packing body cavities, fluid therapy) and more aggressive (blood transfusion, surgical interventions) techniques for management (7,8). Unfortunately, fundamental differences in etiology and presentation limit direct comparisons among species.
It is possible that the early implementation of vasopressor and inotropic therapies masked the physiological signs of the uterine hemorrhage, complicating the detection of ongoing hemorrhage. Usually, a reduction in heart rate would be expected following correction of hypovolemia and hypotension. In this case, the minimal change in heart rate may have reflected an ongoing physiological response to hemorrhage. Perhaps greater volumes of crystalloid, hypertonic saline, and/or colloid fluids may have mitigated the prolonged pressure support in this case and the need for transfusion, especially considering blood lactate was within reference range, suggesting that oxygen delivery was sufficient to avoid significant generalised hypoxia and anaerobic metabolism. A greater effort to quantify the blood loss (e.g., weighing absorbent pads) may have provide earlier evidence of an acute hemorrhage and supported the decision to transfuse, though the exact volume remaining in the uterus would have remained unknown.
Peripartum hemorrhage (PPH) is a possible complication following cesarean section in dogs and cats (1). Oxygen delivery in the body is dependent on cardiac output (Q), hemoglobin concentration, and the saturation of hemoglobin with oxygen (2). Hemorrhage causes a reduction in hemoglobin concentration and Q. The measurement of Q is rarely performed in practice, instead arterial blood pressure and heart rate are used as surrogates. Classical physiological responses to hemorrhage are tachycardia and vasoconstriction; however, general anesthesia with volatile agents blunts these responses and intraoperative intravenous fluid therapy (IVFT) can further decrease hemoglobin concentration. Additionally, normal physiological changes in the pregnant bitch (relative anemia, increased heart rate, and a poor reflex response to hypovolemia) further confound the interpretation of hemorrhage during anesthesia (3). The decision to transfuse a patient in response to hemorrhage is based on evaluating these physiological responses alongside quantified blood loss, the presence of acute anemia (hematocrit < 25%), and evidence of tissue hypoxia (e.g., blood hyperlactatemia) (4). The management of a severe case of PPH has not been described in the small animal veterinary literature. This case report describes the anesthetic and critical care support of a dog with PPH that demonstrated evidence of hemorrhagic shock post-procedure; urgent transfusion therapy was required to stabilize the dog. This case has altered the authors’ institutional practice and resulted in a change in management technique for cesarean sections.