By Claudio Lagoa, DVM, MS
"How do you make a million dollars breeding dogs? Start with 2 million dollars" – the saying goes. Breeding dogs is not cheap…monetarily, emotionally, or with the amount of time invested. Precious lives are involved. Lamentably, few people breed dogs responsibly.
I have always passionately loved dogs. But sometimes, the interaction with some clients and breeders can become a source of major frustration - an experience shared by many of my colleagues. And while some clients and breeders are to be praised for their avid interest in searching for medical information to improve the health & care of their beloved pets, one thing needs to be very clear: neither Dr. Google nor books from your local library will ever be able help you attain the same level of expertise of a DVM for a very simple reason: veterinarians spend thousands of hours learning complex concepts in physics, chemistry (general, organic and inorganic); genetics (basic and advanced); basic and applied physiology; pathology; microbiology; medicine, surgery, etc. -- these are only a few disciplines that we must tackle during our many years in vet school. Then, add to that the complexity of combining theory & practice to become a seasoned vet – something that may take years to achieve. Veterinary medicine (like human medicine) is an ever-evolving science, requiring constant dedication to keep us abreast of new advances. To make things even more ghastly, some vets will go on to pursue advanced training – be it in research (masters or a PhD) or a clinical residency program and sometimes all of the above. Every year vets must comply with state board regulations and complete a certain number of credits in continuing education, or else, lose the license. As you can see, learning is never-ending. Every day I still find myself returning from work only to get immersed in veterinary books and scientific articles – all of this to assure that I am doing what is best for my patients. But all of the above may not be enough for veterinarians to convince "all-knowing clients" to do what is best for their pets. Many will contend that they know more than their vets. And while the digital era has made the dissemination of information easily available and contributed to great strides in some areas such as preventive medicine and welfare, in some areas, this has not been for the better. One of these areas has to do with the fad of cesarean section (C-section) in bitches.
Cesarean section has been part of human culture since ancient times and there are tales in both Western and non-Western cultures of this procedure resulting in live mothers and offspring. According to Greek mythology Apollo removed Asclepius, founder of the famous cult of religious medicine, from his mother's abdomen. Numerous references to cesarean section appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folklore. Yet, the early history of cesarean section remains shrouded in myth and is of dubious accuracy. Even the origin of "cesarean" has apparently been distorted over time. It is commonly believed to be derived from the surgical birth of Julius Caesar; however, this seems unlikely since his mother Aurelia is reputed to have lived to hear of her son's invasion of Britain. At that time the procedure was performed only when the mother was dead or dying, as an attempt to save the child for a state wishing to increase its population. Roman law under Caesar decreed that all women who were so fated by childbirth must be cut open; hence, cesarean. Other possible Latin origins include the verb "caedare," meaning to cut, and the term "caesones" that was applied to infants born by postmortem operations. Ultimately, though, we cannot be sure of where or when the term cesarean was derived. Until the sixteenth and seventeenth centuries the procedure was known as cesarean operation. This began to change following the publication in 1598 of Jacques Guillimeau's book on midwifery in which he introduced the term "section." Increasingly thereafter "section" replaced "operation".
In the bitch, C-sections are done with the intention of saving the life of the bitch and as many puppies as possible. Most often, dystocia (complicated/obstructed delivery) necessitates an emergency C-section. By this time, one or more of the fetuses may be dead or compromised and the mother weak or debilitated. In some – but not all cases - planning a Cesarean section can prevent fetal or maternal loss and can eliminate midnight emergency calls to the veterinarian.
In human medicine, the culture of giving birth has changed drastically since 1970. The caesarean section, once known as a life-saving medical procedure to be used under extraordinary circumstances, is now perceived by the medical profession and their female patients as a safe, painless, modern, and ideal form of birth for any pregnant woman. Certainly, this cultural phenomenon has now extended beyond the medical arena to affect veterinarians and their clients as well.
In human medicine doctors have appropriated cultural values regarding the female body and sexuality and reinforced a blind fascination with technology and medicalized women's fear of labour to justify their preference for surgical births. By narrowing ethical concerns to the doctor-patient relationship and drawing on the notion of the patient's best interest, physicians defend their practice of C-sections as appropriate -- and even desirable. Likewise, the widespread use of C-sections in bitches follows similar trends. On one hand, veterinarians have appropriated breeders’ perceptions regarding the subjective value of a bitch or sire (particularly in the context of dog shows) to justify that they are acting in their client’s best interest while capitalizing on the number of procedures performed. On the other hand, breeders lured by advances in veterinary technology have easily accepted C-sections as a safe procedure, and routinely turn to them for two main reasons: first for convenience; understandably, breeders dread the late night or weekend delivery. And as the noun implies, "labour" involves really hard work: whelping a bitch requires many hours of preparation, attention and stress as the owner has to monitor and assist the bitch (and puppies) during and after delivery. It is not uncommon for dedicated owners to be up for 12-24hrs when a bitch is in labour. Secondly, breeders elect C-sections in hopes of maximizing their financial gain; many naïvely believe that C-Sections can miraculously deliver them more viable puppies (regardless of the risks involved for the dam and litter) and will often pressure veterinarians into performing the procedure. Sadly, in our fast-paced, digitalized, touch-screen, theme park, multi-level, homogenize-the-world mochaccino-era, the commitment to vaginal whelping is dwindling among breeders.
In human medicine, most U.S. experts—whether high-risk obstetricians or home-birth midwives—agree that the U.S. C-section rate is higher than medically necessary and acknowledge that many women are undergoing major surgery for unnecessary reasons. Jeffrey Ecker, MD. ’88, professor of obstetrics, gynecology, and reproductive biology, is a high-risk obstetrician at Massachusetts General Hospital and director of his department’s quality and safety program. A few years ago, working with the Massachusetts Department of Public Health, he compared C-section rates among the commonwealth’s hospitals. The study, like similar ones in other states, found great disparities: Massachusetts hospitals showed as much as a threefold variation in frequency of cesareans. These disparate rates, Ecker says, "can’t all be optimal," and, he adds, it’s "certainly very difficult to demonstrate that higher cesarean rates are associated with better outcomes."
Undoubtedly, some dog breeds need higher caesarean section rates compared to others. In a research published in the Journal of Small Animal Practice (2008), Dr. Evans KM demonstrated that the breeds with the highest caesarean rates were the Boston terrier, bulldog, French bulldog, mastiff, miniature bull terrier, German wirehaired pointer, Clumber spaniel, Pekingese and Dandie Dinmont terrier. In the Boston terrier, bulldog and French bulldog, the rate was > 80%. A higher incidence of dystocia in brachycephalic breeds (breeds with shortened heads/faces such as Bulldogs and Boston Terriers) is a non-intuitive, expected finding. Why the incidence of C-sections is increasing in all breeds demands a reasonable scientific justification - one I presume does not exist.
The majority of clients who come to the ER to get a C-section are in panic mode. They do not know when the litter is due because they often breed their dogs without veterinary assistance. Accurate prediction of the due date relies on hormonal evaluation of the bitch BEFORE BREEDING. Common sense calls for the routine assessment of any dog(s) for breeding purposes by a licensed veterinarian. Why so many clients decline a simple physical exam, vaginal cytology and blood work for less than $250 is mind-boggling. The proper coordination of breeding with vaginal cytology, serum luteinizing hormone (LH) and serial progesterone measurements often allow a more accurate prediction of whelping date. Measuring blood levels of progesterone can also give an idea of whether whelping is imminent because the levels fall when puppies are ready to come out. Usually, levels of 2-3ng/ml are considered low enough to raise suspicion and demand close observation for imminent labor. However, it is not uncommon for bitches to maintain progesterone levels around 2-4ng/ml for a few days before whelping, which can throw some confusion in regards to "readiness" for birth.
Clients must recognize that a C-section should be used only for high-risk pregnancies (brachycephalic dogs, for instance) or for emergency situations, as C-sections can disrupt many important physiological processes that can be detrimental to both dam and newborn puppies. Above all, it is important for clients to understand that it is FETAL MATURATION - NOT THE MOTHER that sets the time for delivery. In late pregnancy, fetal cortisol secretion stimulates lung surfactant production, activates hepatic, and gastric enzymes, and promotes overall final fetal maturation. Subjecting the infant to the expulsive/mechanical forces of vaginal birth is also critical for proper perinatal pulmonary (lung) adaptation. For instance, studies have shown that the absence of a compressive force in the fetal chest while passing through the birth canal reduces the breathing reflex in neonates delivered by C-section. Babies born by C-sections lack the rapid clearance of fetal lung fluid promoted by the normal physiological hormonal environment present in spontaneous labor. Additionally, surfactant synthesis – an essential molecule for proper post-natal lung function/respiration -- is only produced when babies are fully developed and ready for life outside the uterus. If puppies are delivered prematurely, the absence, deficiency or inactivation of surfactant can lead to severe respiratory dysfunction (neonatal respiratory distress syndrome), which is one of the most common of neonatal complications in premature infants. A study recently published in the Journal of Veterinary and Emergency & Critical Care demonstrated that puppies born by elective C-section PRIOR to the onset of expulsive uterine contractions had significantly lower mature amniotic surfactant concentration compared to those delivered by vaginal birth, which indicates incomplete pulmonary maturation. Finally, C-sections require general anesthesia, which further contributes to respiratory depression in puppies. Consequently, babies delivered by C-section may inevitably experience respiratory distress due to ineffective fluid absorption by the lungs, due to lack of adequate amounts of mature surfactant and depression of breathing efforts by anesthetics. Controlled studies in human medicine have demonstrated that babies born via C-section have higher incidence of obesity and asthma later in life. Women subjected to C-section face greater likelihood of future complications in pregnancy, including uterine rupture or conditions in which the placenta covers the opening to the cervix (placenta previa), adheres abnormally to the uterine wall (placenta accreta), or separates from it (placenta abruption). These women are also less likely to breast-feed, and may be at greater risk for depression and post-traumatic stress. Likewise, bitches can experience hurdles as well. They are subject to complications such as intra and post-operative hemorrhage, placental retention, infection, blood clots, uterine scars, bladder damage and possible bowel obstruction. Insufficient mothering instinct or rejection of newborns in dogs is likely to be more prevalent in C-sections and may result from inappropriate hormone balance and/or post-operative pain.
Even if clients insist on having puppies surgically delivered, the dam should be allowed to progress as far as is practical and possible into labor. She needs time to concentrate on licking her nipples and vulva (and everything else within reach) and with your good vet standing by, it is safe. The pre-delivery licking coincides with the release of endorphins and hormones which lay an important foundation for the bonding behavior between mother and whelp. The first time dam who is trotted off to surgery without benefit of the nesting, licking and cleaning behavior is one who will most likely never develop good mothering skills. She is more apt to reject or be frightened by those odd squirmy little things she awakens to find in her bed. Conversely, the dam you allowed to become serious about licking, digging, and arranging her bed can be taken straight into surgery and home as soon as possible. That way, she will take up where she left off as soon as she's regained her wits.
In conclusion, since there is no safe, effective way to induce canine labor, the practice of elective caesarian has grown by leaps and bounds. While doing a C-section can save the bitch and/or puppies in an emergency, it should never be done as a matter of convenience. In the broadest sense, attaining an optimal C-section rate in bitches may be a matter of finding a middle ground between two approaches to birth and risk—between vigilance toward the "disaster waiting to happen" and support for the "physiologically sound process." That way, surgery happens when necessary, but is avoided in the many cases when it’s not.
I have always passionately loved dogs. But sometimes, the interaction with some clients and breeders can become a source of major frustration - an experience shared by many of my colleagues. And while some clients and breeders are to be praised for their avid interest in searching for medical information to improve the health & care of their beloved pets, one thing needs to be very clear: neither Dr. Google nor books from your local library will ever be able help you attain the same level of expertise of a DVM for a very simple reason: veterinarians spend thousands of hours learning complex concepts in physics, chemistry (general, organic and inorganic); genetics (basic and advanced); basic and applied physiology; pathology; microbiology; medicine, surgery, etc. -- these are only a few disciplines that we must tackle during our many years in vet school. Then, add to that the complexity of combining theory & practice to become a seasoned vet – something that may take years to achieve. Veterinary medicine (like human medicine) is an ever-evolving science, requiring constant dedication to keep us abreast of new advances. To make things even more ghastly, some vets will go on to pursue advanced training – be it in research (masters or a PhD) or a clinical residency program and sometimes all of the above. Every year vets must comply with state board regulations and complete a certain number of credits in continuing education, or else, lose the license. As you can see, learning is never-ending. Every day I still find myself returning from work only to get immersed in veterinary books and scientific articles – all of this to assure that I am doing what is best for my patients. But all of the above may not be enough for veterinarians to convince "all-knowing clients" to do what is best for their pets. Many will contend that they know more than their vets. And while the digital era has made the dissemination of information easily available and contributed to great strides in some areas such as preventive medicine and welfare, in some areas, this has not been for the better. One of these areas has to do with the fad of cesarean section (C-section) in bitches.
Cesarean section has been part of human culture since ancient times and there are tales in both Western and non-Western cultures of this procedure resulting in live mothers and offspring. According to Greek mythology Apollo removed Asclepius, founder of the famous cult of religious medicine, from his mother's abdomen. Numerous references to cesarean section appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folklore. Yet, the early history of cesarean section remains shrouded in myth and is of dubious accuracy. Even the origin of "cesarean" has apparently been distorted over time. It is commonly believed to be derived from the surgical birth of Julius Caesar; however, this seems unlikely since his mother Aurelia is reputed to have lived to hear of her son's invasion of Britain. At that time the procedure was performed only when the mother was dead or dying, as an attempt to save the child for a state wishing to increase its population. Roman law under Caesar decreed that all women who were so fated by childbirth must be cut open; hence, cesarean. Other possible Latin origins include the verb "caedare," meaning to cut, and the term "caesones" that was applied to infants born by postmortem operations. Ultimately, though, we cannot be sure of where or when the term cesarean was derived. Until the sixteenth and seventeenth centuries the procedure was known as cesarean operation. This began to change following the publication in 1598 of Jacques Guillimeau's book on midwifery in which he introduced the term "section." Increasingly thereafter "section" replaced "operation".
In the bitch, C-sections are done with the intention of saving the life of the bitch and as many puppies as possible. Most often, dystocia (complicated/obstructed delivery) necessitates an emergency C-section. By this time, one or more of the fetuses may be dead or compromised and the mother weak or debilitated. In some – but not all cases - planning a Cesarean section can prevent fetal or maternal loss and can eliminate midnight emergency calls to the veterinarian.
In human medicine, the culture of giving birth has changed drastically since 1970. The caesarean section, once known as a life-saving medical procedure to be used under extraordinary circumstances, is now perceived by the medical profession and their female patients as a safe, painless, modern, and ideal form of birth for any pregnant woman. Certainly, this cultural phenomenon has now extended beyond the medical arena to affect veterinarians and their clients as well.
In human medicine doctors have appropriated cultural values regarding the female body and sexuality and reinforced a blind fascination with technology and medicalized women's fear of labour to justify their preference for surgical births. By narrowing ethical concerns to the doctor-patient relationship and drawing on the notion of the patient's best interest, physicians defend their practice of C-sections as appropriate -- and even desirable. Likewise, the widespread use of C-sections in bitches follows similar trends. On one hand, veterinarians have appropriated breeders’ perceptions regarding the subjective value of a bitch or sire (particularly in the context of dog shows) to justify that they are acting in their client’s best interest while capitalizing on the number of procedures performed. On the other hand, breeders lured by advances in veterinary technology have easily accepted C-sections as a safe procedure, and routinely turn to them for two main reasons: first for convenience; understandably, breeders dread the late night or weekend delivery. And as the noun implies, "labour" involves really hard work: whelping a bitch requires many hours of preparation, attention and stress as the owner has to monitor and assist the bitch (and puppies) during and after delivery. It is not uncommon for dedicated owners to be up for 12-24hrs when a bitch is in labour. Secondly, breeders elect C-sections in hopes of maximizing their financial gain; many naïvely believe that C-Sections can miraculously deliver them more viable puppies (regardless of the risks involved for the dam and litter) and will often pressure veterinarians into performing the procedure. Sadly, in our fast-paced, digitalized, touch-screen, theme park, multi-level, homogenize-the-world mochaccino-era, the commitment to vaginal whelping is dwindling among breeders.
In human medicine, most U.S. experts—whether high-risk obstetricians or home-birth midwives—agree that the U.S. C-section rate is higher than medically necessary and acknowledge that many women are undergoing major surgery for unnecessary reasons. Jeffrey Ecker, MD. ’88, professor of obstetrics, gynecology, and reproductive biology, is a high-risk obstetrician at Massachusetts General Hospital and director of his department’s quality and safety program. A few years ago, working with the Massachusetts Department of Public Health, he compared C-section rates among the commonwealth’s hospitals. The study, like similar ones in other states, found great disparities: Massachusetts hospitals showed as much as a threefold variation in frequency of cesareans. These disparate rates, Ecker says, "can’t all be optimal," and, he adds, it’s "certainly very difficult to demonstrate that higher cesarean rates are associated with better outcomes."
Undoubtedly, some dog breeds need higher caesarean section rates compared to others. In a research published in the Journal of Small Animal Practice (2008), Dr. Evans KM demonstrated that the breeds with the highest caesarean rates were the Boston terrier, bulldog, French bulldog, mastiff, miniature bull terrier, German wirehaired pointer, Clumber spaniel, Pekingese and Dandie Dinmont terrier. In the Boston terrier, bulldog and French bulldog, the rate was > 80%. A higher incidence of dystocia in brachycephalic breeds (breeds with shortened heads/faces such as Bulldogs and Boston Terriers) is a non-intuitive, expected finding. Why the incidence of C-sections is increasing in all breeds demands a reasonable scientific justification - one I presume does not exist.
The majority of clients who come to the ER to get a C-section are in panic mode. They do not know when the litter is due because they often breed their dogs without veterinary assistance. Accurate prediction of the due date relies on hormonal evaluation of the bitch BEFORE BREEDING. Common sense calls for the routine assessment of any dog(s) for breeding purposes by a licensed veterinarian. Why so many clients decline a simple physical exam, vaginal cytology and blood work for less than $250 is mind-boggling. The proper coordination of breeding with vaginal cytology, serum luteinizing hormone (LH) and serial progesterone measurements often allow a more accurate prediction of whelping date. Measuring blood levels of progesterone can also give an idea of whether whelping is imminent because the levels fall when puppies are ready to come out. Usually, levels of 2-3ng/ml are considered low enough to raise suspicion and demand close observation for imminent labor. However, it is not uncommon for bitches to maintain progesterone levels around 2-4ng/ml for a few days before whelping, which can throw some confusion in regards to "readiness" for birth.
Clients must recognize that a C-section should be used only for high-risk pregnancies (brachycephalic dogs, for instance) or for emergency situations, as C-sections can disrupt many important physiological processes that can be detrimental to both dam and newborn puppies. Above all, it is important for clients to understand that it is FETAL MATURATION - NOT THE MOTHER that sets the time for delivery. In late pregnancy, fetal cortisol secretion stimulates lung surfactant production, activates hepatic, and gastric enzymes, and promotes overall final fetal maturation. Subjecting the infant to the expulsive/mechanical forces of vaginal birth is also critical for proper perinatal pulmonary (lung) adaptation. For instance, studies have shown that the absence of a compressive force in the fetal chest while passing through the birth canal reduces the breathing reflex in neonates delivered by C-section. Babies born by C-sections lack the rapid clearance of fetal lung fluid promoted by the normal physiological hormonal environment present in spontaneous labor. Additionally, surfactant synthesis – an essential molecule for proper post-natal lung function/respiration -- is only produced when babies are fully developed and ready for life outside the uterus. If puppies are delivered prematurely, the absence, deficiency or inactivation of surfactant can lead to severe respiratory dysfunction (neonatal respiratory distress syndrome), which is one of the most common of neonatal complications in premature infants. A study recently published in the Journal of Veterinary and Emergency & Critical Care demonstrated that puppies born by elective C-section PRIOR to the onset of expulsive uterine contractions had significantly lower mature amniotic surfactant concentration compared to those delivered by vaginal birth, which indicates incomplete pulmonary maturation. Finally, C-sections require general anesthesia, which further contributes to respiratory depression in puppies. Consequently, babies delivered by C-section may inevitably experience respiratory distress due to ineffective fluid absorption by the lungs, due to lack of adequate amounts of mature surfactant and depression of breathing efforts by anesthetics. Controlled studies in human medicine have demonstrated that babies born via C-section have higher incidence of obesity and asthma later in life. Women subjected to C-section face greater likelihood of future complications in pregnancy, including uterine rupture or conditions in which the placenta covers the opening to the cervix (placenta previa), adheres abnormally to the uterine wall (placenta accreta), or separates from it (placenta abruption). These women are also less likely to breast-feed, and may be at greater risk for depression and post-traumatic stress. Likewise, bitches can experience hurdles as well. They are subject to complications such as intra and post-operative hemorrhage, placental retention, infection, blood clots, uterine scars, bladder damage and possible bowel obstruction. Insufficient mothering instinct or rejection of newborns in dogs is likely to be more prevalent in C-sections and may result from inappropriate hormone balance and/or post-operative pain.
Even if clients insist on having puppies surgically delivered, the dam should be allowed to progress as far as is practical and possible into labor. She needs time to concentrate on licking her nipples and vulva (and everything else within reach) and with your good vet standing by, it is safe. The pre-delivery licking coincides with the release of endorphins and hormones which lay an important foundation for the bonding behavior between mother and whelp. The first time dam who is trotted off to surgery without benefit of the nesting, licking and cleaning behavior is one who will most likely never develop good mothering skills. She is more apt to reject or be frightened by those odd squirmy little things she awakens to find in her bed. Conversely, the dam you allowed to become serious about licking, digging, and arranging her bed can be taken straight into surgery and home as soon as possible. That way, she will take up where she left off as soon as she's regained her wits.
In conclusion, since there is no safe, effective way to induce canine labor, the practice of elective caesarian has grown by leaps and bounds. While doing a C-section can save the bitch and/or puppies in an emergency, it should never be done as a matter of convenience. In the broadest sense, attaining an optimal C-section rate in bitches may be a matter of finding a middle ground between two approaches to birth and risk—between vigilance toward the "disaster waiting to happen" and support for the "physiologically sound process." That way, surgery happens when necessary, but is avoided in the many cases when it’s not.
