"Have you picked up Dr. Katie?”
“No, she says I need to be patient. Hopefully she will be discharged before six. Can you keep the day open, I don’t feel like doing too much?”
”Its too late for those thoughts. We have a C-section coming in.”
“On Frenchie, a bulldog. Remember Dana Zubia?”
“Oh, the artificial insemination we never did? The stud dog was too scared to maintain an erection. I was sure it wouldn’t happen.”
“Well it did. You showed Dana how to do it, you gave her gloves, and the insemination equipment and she went home and tried again.”
“I guess she paid enough attention.” He sighed over the phone. “So, why does she think its time?”
“Frenchie's temperature dropped last night, and she’s scratching at her bedding, exhibiting nesting behavior.”
“Have you done a C-section before?”
“Twice,” she replied proudly.
“Well good, I'm glad to hear it.” He chuckled. “Make sure we have sterilized drapes and packs.”
“Well good, I'm glad to hear it.” He chuckled. “Make sure we have sterilized drapes and packs.”
“Okay, when will she be there?”
“She’s already here and wait till you see how big mama is, Doc. How long will you be?”
“About fifteen minutes.”
Honey and Dana had the bitch on the table. They had clipped her belly hair and were ready for the surgery when Rory came in. He was impressed Honey knew her stuff.
“Don’t forget to shave her arms. I want to give her drugs through a cephalic catheter.” After Honey finished vacuuming the hair off the belly, he collected his arm catheter, and a few more things; tape, flush, and a cap to keep it in the right place. He showed Honey how to hold the arm correctly and placed the catheter on the first attempt.
“Impressive, Doc.” Honey was proud of his skill.
“Thanks,” he said as he injected a low dose, pre-op sedative under the dog’s skin. This will give us ten minutes of prep time before induction. Now let’s make sure we have our places and everyone knows what to do. Have you done a surgical scrub before on your hands, Honey? I need you to be my assistant surgeon, and Dana will be the wet nurse.”
“I’m not sure what you mean by a scrub on my hands.”
“Oh okay. Here, put your hand against mine. I use size 8 gloves. You’re about the same, maybe a little smaller. Let's look for size 7. Oh, here’s some. They're sterile; they're still in the packaging. You also need a cap and facemask. Now, when you wash your hands you need to use this surgical scrub brush. Soap up each finger, and scrub a lot, first under each nail, then around each finger. Think of fingers having four sides, and make sure you run the scrub brush up and down each finger, getting here onto the web between each finger, like this. Good. Now scrub the top of your hand, the bottom, and each side down to your wrists. That’s right, you’re good to go. You need to repeat this when I’m ready for your help in the surgery.”
“Got it, Doc.”
“Now it’s time to quiz Dana and anesthetize the bitch. What experience do you have as a wet nurse, Dana?”
“I’ve done this before,” she replied, “but what would you like me to do?”
“I’ll be handing each puppy to Honey, who will carry it from surgery to you, here in the treatment room. I want you to strip off the membranes from the head and clear the nostrils. The normal delivery process automatically squeezes fluid from the lungs when the puppy is pushed through the birth canal. Because a C-section doesn’t do these types of compressions you may need to fling the puppy down fast while pointing its head to the floor. It helps drive fluid from the lungs. We can also have these small TB syringes ready to act as suction devices if you see persistent bubbles frothing from the nostrils.”
“I can do that.”
“Okay, she’s ready,” Rory said when he saw the bitch wretch up stomach contents. “The pre-op is working. Let me do a last check on the heart rate.” He placed his stethoscope in his ears to make sure the heartbeat was steady. It was. “Everything looks ready, let’s induce.”
“What is the white stuff, the anesthesia Doc?” Honey asked. “I’ve only seen Doc Collins use clear anesthetics.”
“This is propofol, it's an anesthetic. I don’t usually use it often because it’s short acting; it lasts only five or ten minutes. It’s good for C-sections because it doesn’t cross through the placentas. The babies are more alert when they are delivered because they aren’t doped up. The old medicine made them drowsy, and it was harder to stimulate the puppies to breathe. I need to show Dana how to give it through the catheter while we are in surgery.”
Rory injected half a syringe of the drug into the catheter, and waited about a minute for the bitch to really go to sleep. Her body slumped into a relaxed heap. He checked her jaw tone, and was able to open her mouth easily. “Ok, now we need to place the endotracheal tube in her windpipe.” He picked up a clear plastic tube a foot long, and squinted into the deep recesses of the oral cavity to make sure he was placing the tube in the right hole. “Got it,” he said, as he tied string around the tube and looped it around the dog’s nose, finishing the attachment in a bow tie. “Now we puff up the cuff on the tube to make all the anesthetic gas stay inside the tubes, and we're done with the prep.”
He rolled her upside down to do a final check on the shaved site and decided to proceed. “Let’s carry her to surgery.”
They placed the bitch on her back on the table, securing her legs with ties, and hooked up the ET tube to the anesthesia machine.
“What level of isoflurane do you want, Doc?” Honey asked.
“I don't want any right now. Just give her oxygen. I don’t want the anesthesia gas started until the puppies are out.” They hooked up the respiration monitor, and heard a reassuring beep every time the bitch inhaled. The breathing rate remained slow and steady.
“Ok Honey, you stay here, and finish her scrub. I’m going to gown up. As soon as I get back you can scrub in.”
A few minutes later he was back, dressed in a surgical gown, holding his gloved hands in the air. Do you see how I'm holding my hands? This is the way to keep gloved hands sterile. Never let them drop below the waist because bacteria float around down there. The feet and legs kick it up from the floor. So, when you get your gloves on, keep the hands high, right at head level. Just remember, the risk of contamination increases the closer one is to the floor. Okay, it's your turn to gown up.”
She left as he proceeded to drape the dog. He placed one sterile towel on each side and one at both ends of the surgery site to keep the area Honey disinfected clean and sterile. He unfolded a cloth drape and placed it atop the toweled off section. Because the big drape was three by three feet it gave him a large sterile field to play on, making surgery easier because he wouldn’t have to worry about contamination from hairs or other body parts. He started the surgery before Honey was back. He didn’t need an assistant at this early stage.
Grabbing a stainless steel surgical blade he set it just below the dog’s belly button and gently yet firmly made a clean incision right through the skin into the underlying fatty subcutaneous tissue. He made a straight line from her belly button towards her vulva and stopped when he had a six-inch long incision.
Honey returned, holding her hands up like a well-trained surgeon. Again Rory was impressed with her astuteness. She stood opposite him across the surgery table.
“Your gloved hands are sterile, Honey. You can set them on the drape. It allows you to focus on helping me instead of worrying about contamination.” He took her hands and set them on the drape.
“See this white fatty tissue? It’s subcutaneous fat. I will trim away this fatty tissue in order to see the linea alba, the white line that holds the abdominal muscles together. If I incise only along the white line, the recovery time is lessened because there is little tissue to be mended here.”
Once he cleared the fat from the area, which was easy because this girl had hardly any fat, he picked a spot to prick with his scalpel blade. “You’ve got to be careful here,” he warned Honey. “The babies are forced against the abdominal wall, and pushing too hard can cut the babies in the uterus. I don’t want to have to stitch the skin of a newborn pup just because I was careless.”
He grabbed the linea in order to ‘tent’ the tissue. This is done to lift it up so the scalpel blade can be gently pushed into the bulge without causing inadvertent damage to the uterus and its precious cargo within. Rat-toothed forceps are perfect for the task. They are a simple tweezers-type instrument, with two teeth on one tweezers tong, with one tooth, which fits between the two on the other. This allows easy grab of almost any tissue type, other than bone.
Rory picked the rat-toothed forceps up in his left hand. He made three attempts to gather the linea up in the forceps, but the bitch was too pregnant. There was little give and take, so he had to push a blade carefully through the linea to create a hole, and not go too deep lest he incise the uterus.
He knew he entered the abdomen when he punctured the linea when clear abdominal fluid oozed from inside the belly cavity. This was normal and expected because the puppies were growing bigger each minute, squeezing any extra space to a minimum.
Discarding the scalpel he picked up his metzenbaum scissors to extend the incision downward along the white linea. Because this line is a connection of muscle groups, there is little bleeding when cutting through the white line as no blood vessels are there in the center. It’s just a white band of ligamentous tissue running from sternum to pelvis holding the belly together.
Once the drape and towels are laid the belly can be opened. I made a five inch cut along Roxy's midline. Here I've gone through skin, and the belly muscles. I've isolated part of the gravid uterus between those two fingers. Next I'll exteriorize the uterus by gently working the entire thing up out of the incision. It's tricky, there's a heck of a lot more uterus underneath my fingers.
Rory extended his pinprick incision with the metzenbaums. These tissue scissors have rounded tips so they will not inadvertently pierce important things. The gentle curve of the blades and the rounded tips allow the scissors to glide through tissue with minimal damage. He used them to open the belly up creating a six-inch gash.
“They’re right here, ready to jump out,” he said, seeing the babies inside the thinned out uterus. Setting his scissors down, he focused on exteriorizing the uterus. With both hands he worked his fingers under the left uterine horn and gently coaxed it upward. He repeated the same maneuver with the right horn, pulling all the puppies out into the open. Now they were lying on the outside of mama’s belly, but still ensconced inside her uterus. They looked like sausages inside intestinal casing.
Surprise! This is the entire uterus, comprised of two horns containing puppies on both right and left. Humans have a big circular uterus, the horns aren't needed because most ladies have one maybe two kids at a time. Roxy had five.
“Here’s the tricky part. I have to go into the uterus at the outside border, which means finding the place with the fewest blood vessels. It's the farthest point from the center here. And now that I know where I want to open up, I have to be careful not to puncture a baby with my instruments. Is everyone ready?” Both ladies nodded as he tented the outside border, and pushed his scissors into the thin uterus wall. He opened it wider with his metzenbaums to make it big enough to pop the first babies out.
Here's the first pup. Now the excitement starts. My right hand is feeling for the placenta because the umbilical cord is still attached to the puppy. If the placenta is loosening from its placental attachment site I'll pull it out with the puppy, otherwise I'll put a clamp on the cord when it separates from the placenta. All this happens before I drop the pup into Abi's hands. She'll clean the membranes off the head, clearing mucous and fluid from the nostrils.
In a flash, he plucked the fetus and pulled it free of its mother’s support. As he pulled up on the baby the placenta remained attached to the uterine wall, so he stretched the umbilical cord while lifting the baby out to break it. The placenta stayed attached to the uterus. It would release itself later.
The puppy was vigorously squirming when he dropped it into Honey’s hands.
“It still has membranes covering it, Dana. You need to strip them off and clear the nose so it can start to breath.” He returned to his incision to gently squeeze a second pup into the incised area and repeated the extrication. “Here’s number two,” he said, waiting for Honey to accept the baby from him. He repeated the procedure two more times. “There’s nothing more here in the left horn. Let’s go to the other side. How are you doing, Dana? Ready for the other half?”
Here's number two pointing his nose at us. The first pup's umbilical cord is still attached to the placenta, note how the umbilicus drops into a black thing still within the uterus. That's the placenta.
“Yes doctor, everybody’s looking good.”
He moved to the right uterine horn and carefully made a new incision to set this neighborhood free.
“How many more, Doc?”
“I don’t know, I just take things one at a time. Here, here’s number five, I think, right?”
“One, two, three, four, yes, there are four so far. Thank you Honey, this makes number five, Doctor Evans.”
”These guys are ready so let’s roll, this side is easier.” He slowed his zeal a little to make sure the ladies weren’t overwhelmed.
As soon as Honey returned, he had number six and promptly plopped it into her cupped hands.
“I have another for you, Dana.” Honey handed another puppy over. How many more Doc?”
“Looks like two more, I think. Give me a minute, I need to work these guys into the incision.” He focused for another half minute, milking the last two fetuses toward the surgical opening. “Yep, here’s another, how many do we have?”
“You just gave me number seven.”
“Okay, this is the last one. Here you go. Give this to Dana, then go and change into another pair of gloves, I need your hands in surgery.”
When she returned he asked her to hold each uterine horn steady. “Hold it up higher, and keep the horn straight and tight. Then I can do a running stitch pattern quickly.”
After offering up five puppies, the empty uterus needs to be sutured closed. Here Abi is holding up the end. She's pulling the entire incision taut to allow me easier and quicker closure. With her holding it thusly I can weave the threaded needle more quickly to close that much speedier.
“It’s shrinking, Doc.”
“That’s because the babies are out. The uterus is a muscle, and it’s going back to petite size.”
“I don’t think there’s anything petite about Cocoa,” Honey joked.
“Careful, you’ll hurt her feelings. She might wake up and tell Dana you were calling her names.”
I dropped the uterus back into the belly after suturing to my satisfaction. Now it's time to close the body wall.
“No, I’m joking, you can make fun of her.”
“How are they looking, Dana?” Rory finished the running stitch on the left horn. He checked it with hemostats, trying to push the tip through the sewn up incision. It held tight and didn't allow the tip to nose its way in. “Good, now for the other horn. Hold it up the same way, Honey.”
The first layer is finished. This is the most important holding layer in the closure. I must verify the sutures are tight, and that there are no gaps where intestines could escape through, causing a dehiiscence, a total breakdown of the closure.
“All of them look fine, except one keeps bringing bubbles up at his nostrils.”
The second suture layer is necessary to gather all that subcutaneous tissue together. The aim is to have little available space for liquid to pool. Notice how this second layer is tightening up the gap above the forceps.
“You’ve got to grab the puppy in your hands with the head pointing toward the floor. Now, hold tight and act like your going to throw the thing on the floor. The fling helps drive fluid from the lungs. I can do it for you as soon as I’m done here.” He was checking the second running stitch with hemostats. “The uterus is back together. It’s time to close the abdomen.”
“Do you still need me?” Honey asked, realizing he was almost done.
The final layer is the one everyone sees. Today we use an absorbable monofilament thread that dissolves after three or four weeks.
“No, I can finish. Go help Dana attend to the pups and show her how to swing them to clear their lungs. Oh, turn the isoflurane on, her breathing rate is increasing.”
Here we have Roxy put back together again.
Ten minutes later Rory finished the last skin suture. Sighing in relaxation after being intensely focused for forty minutes he leaned against the counter in the treatment room and watched the girls intently working their new charges.
And here's what makes the surgery so gosh darn fun.