During a Caesarean section the veterinary nurse will work with the veterinary surgeon as an integral member of a team, carrying out several crucial and essential roles. From the outset the nurse may be involved with the initial client communication, through to the preparation of the patient for surgery, anaesthesia monitoring and assisting the veterinary surgeon, revival of the puppies, recovery of the bitch and finally the postoperative care of the bitch and puppies.

Client Communication

When a client with a whelping bitch with dystocia contacts the surgery for advice it may well be out of normal working hours and occur as an emergency; their initial point of contact will almost certainly be with the veterinary nurse. It will be the nurse's responsibility to assess the situation whilst reassuring the client and obtaining an accurate and comprehensive case history. Often it will be the owner's first experience of the situation and they may be very distressed. The nurse must demonstrate a confidence in the situation and show an understanding of the client's feelings. The nurse will contact the veterinary surgeon. It is at this point that the nurse needs to start considering the possibility of a Caesarean section, although that decision will not be confirmed until after the veterinary surgeon has examined the patient.

The veterinary nurse may be required to keep the client informed of the progress of the bitch and pups before and after surgery, and later to advise on their postoperative care.

Preparation

Once surgery has been decided upon the nurse will need to be available to prepare the bitch for the procedure; often, time is of the essence so it is vital that the theatre has been prepared in advance, and all equipment is available that may be required for the bitch or pups. It is advisable for all practices to have their own protocol for this procedure; this will assist staff, especially new members and locums (both nurses and veterinary surgeons), and ensure a consistent and thorough approach to the procedure.

The length of anaesthesia will be kept to a minimum, so steps should be taken to accommodate this. For example if the bitch is amenable, do an initial clip of the surgical site before she is anaesthetised; this can be done with an assist-ant gently lifting her front legs so she does not need to be turned on to her back. Preoperative fluids are usually advisable and should be secured along with another intravenous site prior to anaesthetising.

Anaesthesia and Surgery

The surgeons' common anaesthesia of choice is propofol followed by maintenance with a volatile inhalation anaesthetic, preferably with little or no premedication, as this can depress the foetuses and dam during and after surgery. Due to the effects of pregnancy, hypoventilation can occur causing hypoxia and hypercarbia; it is essential to maintain good oxygenation through intubation and oxygenation. Fluid therapy must be maintained during and after surgery to maintain blood volume and pre-vent hypotension. During anaesthesia have the table tilted to keep the head and chest raised to reduce pressure on the chest. Be prepared for anaesthetic and surgical emergencies, such as haemorrhage or uterine rupture, and also for emesis at induction or during recovery.

Puppy Revival

Where possible the ideal is to have several nurses available to assist in theatre: one to concentrate on the anaesthetic, while the others can attend to the puppies.

Following Caesarean section, puppies will often require considerable resuscitation as they have not gone through the usual stimuli of birth and may be slow to respond to the 'gentle touch'. Firstly clear the puppy's airway using a dry towel, then gentle compression of the chest followed by rubbing firmly all over with a towel may be all that is required to initiate respiratory effort. The puppies may have taken amniotic fluid into their airway; aspirating or gently swinging them whilst supporting their heads will help to remove this. If this does not result in positive respiratory effort but there is a positive heartbeat, administration of a respiratory stimulant such as doxapram HCL (Dopram V Drops) (sublingual) drops may be required. Oxygen can be given via a mask, or artificial resuscitation may be attempted by blowing down the nose of the neonate--care must be taken not to overinflate the lungs. If there is no heart beat resuscitation should be combined with external cardiac massage.

Once revived puppies need to be kept warm at 25-30°C, ideally in an incubator, and constant monitoring is required to ensure their continued progress. Their umbilical cord should be ligated with suture material 3 cm from the abdomen, and they should be checked for any obvious deformities, e.g., cleft palate.

Recovery and Postoperative Care

The recovery of a bitch from Caesarean section is fairly similar to that of any abdominal surgery; however, she will not have had the same premedication and therefore may recover more rapidly. She should stay on intravenous fluids until she is fully conscious and of course it is essential to maintain a warm ambient temperature for her recovery. Before she returns to full consciousness it is useful to take the opportunity to assist the puppies in obtaining a first feed from her, ensuring they consume a colostrum feed. This is time consuming and requires a lot of patience but is very worthwhile, as you cannot know how the bitch will react to her puppies especially if she is a first-time mother. Unlike with other abdominal surgeries it is beneficial for the bitch and puppies to return home as soon as possible after recovery from anaesthesia. The bitch will commonly ignore her puppies until she has returned to her normal home environment, so feeding of the puppies can be problematic in the hospital.

Until the bitch returns home it is advisable to supervise all contact between her and the puppies, to prevent her crushing, ignoring, or being over-attentive to them.

When the bitch is discharged the owners must be supplied with detailed instructions on her recovery and also the care of the puppies. It is also advisable for the veterinary nurse to make a follow-up telephone call to check on the progress of mother and puppies within 24-48 hours of discharge.