Friday, April 29, 2016

33. The Breeder Who Cried Wolf

April 29, 2016

I have my morning off today intending to send a friend off to Japan by driving her to Changi Airport at 8 am.

The breeder phoned at 6.30 am wanting a Caesarean section for his 6lst-day-pregnant Corgi. I cancelled my morning off.

The dam had started contractions at 4.30 am and no pups had been born.

So, I got ready with my assistant to meet him at Toa Payoh Vets. As I was ready to go out, he phoned to say that the Corgi had given birth to a puppy and so he cancelled the appointment. I looked forward to my half day off as I had been working long hours 7 days a week for the past months.

After the first puppy, a second puppy was born naturally at 9.30 am. The dam strained but no puppy was produced and the breeder phoned me at 12 noon to request a Caesarean Section as he knew that the dam have many puppies.

This was a breeder who cried wolf and so I was not going to rush to the Surgery and have him cancel the appointment again. He did not want other vets to operate on his dog.  He had lost 8 Corgi puppies during a C-section done by a younger vet recently and that $40,000 loss of puppies was attributed to an inexperienced vet.

So I rushed back to Toa Payoh Vets and got the Caesarean section done. The dam was passing lots of red blood and this was not a good sign. It indicated that the umbilical cord of a puppy stuck inside the vagina had ruptured its umbilical blood vessels. Lots of red blood dribbled out. The Corgi dam was in pain as she got agitated when I washed her back area to clear the blood.

Isoflurane gas by mask, intubate. My assistant Judy inflated cuff to ensure close fit.
"Maintenance anaesthesia should be less than 2%" I told to monitor closely the dog's vital signs. "In some cases, it could be less than 1.5%. In this careful monitoring, no dam ever died on the operating table. A dead dam is disastrous to the dog breeder as the puppies will have no milk to drink."

Vets must think from the breeder's point of view and a Caesarean section must be done speedily and correctly. I had performed around 5 Caesarean sections for this breeder without any death of the dam and puppies and he was reluctant to try another vet with lesser experience. I had operated over 100 Caaesarean sections for breeders at a time when the breeders lost their regular vet who was de-licensed for a year. So I had a track record and he preferred me to do it.

I am particular about the accuracy of the anaesthetic machine. It must be serviced and able to deliver the correct amount of gas as stated in the meter. If it says 1%, it must produce 1% and not more.
I have a dedicated experienced anaesthetic man who had just maintained the machine and I could use 1.5% to maintain the anaesthesia, using semi-open circuit in this case.  2.5% is advised in some veterinary anaesthesia books and I note that some vets use 3%. That may kill the dam or puppies or both.

A vet's reputation depends on whether he or she can deliver live puppies and dam at the end of the C-section and speed of surgery is paramount. If the vet is tardy, the dam may die from a lengthy surgery and the experienced breeder will blame him or her for being incompetent. This breeder had engaged more than 10 vets to do C-section in the past 40 years and so he could assess the skills of various vets and how he rated them. Still, I cannot be complacent and tardy.

Hartmann's solution was given before op. Calcium is important for this dam.  I added 5% glucose for around 5 minutes and another bottle of Hartmann's plus Vit Bs for this dam.

The gums of this dam were snow white at the end of Caesarean section, indicating a large loss of blood. This dam had an unusual large amount of bleeding as one dead pup with the tongue sticking out had already separated from the placenta and blood vessels as it was stuck inside the vaginal canal (video). I had the blood aspirated from the abdomen before closing and that added some minutes to the operation. I feared that this dam would die from haemorrhage.

The textbook advise a long incision and exteriorize the gravid uterus. This takes four times as long and the wound is lengthy. I made a short incision twice the width of the Corgi puppy's head. That would be around 10-15 cm of the skin incision. The uterine bifurcation is palpated and I made a similar length uterine incision and use my fingers to hook out the puppies. I exteriorize the uterus after all 5 puppies had been manipulated out to ensure no puppies have been hidden deep inside the rib cage area. I believe that a small skin incision will be better for the dam and has less likelihood of stitch breakdown and this is true for my over 100 cases of C-sections done. The vet textbook still advises the very long incision of the abdomen so that the whole uterus can be taken out and the puppies can be milked out easily. Operating time to stitch up the wound takes much more time.

SAC - Speed, Accuracy and Completeness in surgery.
Speed - A surgeon has less risk of anaesthetic death if he can be speedy in surgery.
Accuracy - Know the anatomy and where to cut
Completeness - Ensure that no puppies are left behind

In this case, I injected methone at 0.25 mg/kg SC (10mg/ml) and gave 0.3 ml SC. I phoned the breeder at 9 pm, some 8 hours after the surgery. He said that the dam had an excellent appetite on going home from the C-section. I attributed this to the pain-killing effect of methone. Usually I use tolfedine which may not be so effective as a painkiller but there is no scientific study done by me.

The breeder had given 0.5 ml of oxytocin and another 0.5 ml of oxytocin to get uterine contractions. The contractions started at 4.30 am. lst pup was born at 6.45 am. 2nd pup was born at 9.30 am and no more. Caesarean section started at 12.30 pm and one pup with the tongue sticking out of the mouth would have died inside. Another pup was distressed. Altogether 5 pups. 4 were alive.

If the breeder did not cry wolf, the dead pup would be alive as C-section would be performed at 7 am as I had prepared for the operation.

Despite some 40 years of experience as a breeder, there is much to learn. My advice to the breeder is to get an elective C-section done if the dam has more than 4 puppies and if the time interval between pups is more than 2 hours. This is from experience and from some breeding books I read.

B:  12.20pm Isoflurane gas by mask first, then intubate
C:  1.33 pm  Gas stopped.
D:  12.40pm  First skin incision
E: 1.33pm     Completed skin stitching

E-B = 73 minutes

Maintenance of gas  1-2% generally.


12.52 pm. Started stitching uterus. 2 rows.  5 puppies handed to breeder with umbilical cords clamped with forceps.
1.04 pm  Uterus stitching completed.   My assistant commented that I took a long time to stitch the uterus as compared to taking out the 5 puppies from the uterus. The time taken to stitch is 12 minutes as the uterine incision was 4 inches long and I stitched two rows.

Compare to the Yorkshire Terrier stitching of uterus (earlier case) - Caesarean section around Apr 22, 2016.

9.28 pm Started stitching uterus. 2 rows.  5 puppies handed to breeder with umbilical cords clamped with forceps.
9.43 pm  Uterus stitching completed.
Time taken is 15 minutes

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