47. Oxytocin v. elective Caesarean section

If the female dog can't give birth naturally, give an injection of oxytocin and see what happens. This is fine in theory and in lectures.

In private practice, the owner wants a good outcome when he brings in a barrel-shaped Miniature Schnauzer that had difficulty in giving birth to the vet for Caesarean section. With a fully distended abdomen, the Schnauzer is likely to have 5 or 6 puppies. In this case, an X-ray by a vet said 4 puppies but the owner did not bring the X-ray.

Now, what the owner wants is that he gets all puppies alive and ensure that the dam is safe. Oxytocin may or may not work.

If it does not work, there is a long delay which may result in a dead pup or two. If it works, the first pup may be delivered but not every of the 5 pups. A Caesarean section will still be needed and one of the pups may have died in the interim period.

Therefore, in theory, your lecturer advises oxytocin injection to wait and see. Oxytocin does work in some cases but you have to wait. Assuming that the first pup is born 30 minutes after the oxytocin injection, it does not mean that the second pup will follow. If the second pup is born naturally, the 3rd pup may be too big to follow or the dam may be too weak to contract. A few hours pass by. The remaining pups go into distress. When the Caesarean section is performed, one pup may have died. So what? As a vet, you have nothing to lose but your reputation. Some vets don't care about their reputation because deaths are part and parcel of veterinary practice.

In this particular case, at the 6lst day of pregnancy and rectal temperature of 37.1 deg C, I would do an elective Caesarean section. No mucking around with oxytocin to wait and see. It was obvious from the barrel-shaped abdomen that the dam had large pups (X-ray by a vet said 4 pups).

This case was not my case and therefore the judgment to wait after oxytocin injection or do a Caesarean section would be the other vet's judgment. I was an observer. It was Chinese New Year's Eve and my day off as it was also a Saturday. A blue sky, white clouds sunny day.

I did not have a car and taxis would be hard to flag down since most people in Singapore seemed to have closed in the afternoon. The vet in charge decided on a Caesarean section. It was such a bright sunshine afternoon and the lighting would be excellent for beautiful puppy photography. So, I hitched a motor bike ride from Mr Goose to transport me to the other vet practice so that I could take some good pictures of new born puppies. I love taking pictures of neonate puppies. They represent new life.



For the past 20 years, I had never had to ride a bike. I may be a senior citizen but I am still kicking and alive. So I rode pillion behind Mr Goose who is a careful man. His small red bike chugged along as if groaning under my weight. His bike is similar to the ones I show in the picture below. Nothing fanciful.



I put my hands on his shoulders in case I fell off. I hoped for the best. Bike accidents are common in Singapore and here I was taking a calculated risk that no other cars would collide into me from the side or behind.



Mr Goose had one or two minor accidents in the past 10 years and that was considered an excellent safety record. So, I trusted him. So, I had to strain my right hip to get onto the back seat. My backpack with my camera took up some space and so we went down the expressway. Cars whizzed by. I kept my fingers crossed and onto the shoulders of Mr Goose. I tried to maintain an upright posture as he swerved and turn to reach the practice.

The wind from Mr Groove's helmet whistled into my helmeted ears. The afternoon sky was blue. White cotton clouds dotted the sky and bright sunshine radiated downwards as I enjoyed the fresh breeze. Fortunately, it was not a rainy day and we arrived safely.

All 5 puppies were delivered by Caesarean section by the vet. I took a few pictures. This was a day full of happy memories for of a Chinese New Year's Eve on a very rare instance when I got onto a motor bike.

Births of new pups are always wonderful. New born pups are hard to photograph. The evening sunshine was what I wanted to get a good picture. Now it was up to my expertise to produce some for readers. I did not have to use Photoshop to touch up. There were some of my favourite pictures. I hope the readers enjoy them and wish all a Happy Chinese New Year 2010.

I am quite sure that the family of 5 Miniature Schnauzer pups must be having a very happy New Year too. I don't know them nor did I meet them as this was not my case. Senior citizens do not need to behave and walk as if they have one foot in the grave. Be alive. Think alive. Old age does not mean impending death. Live life as if every day is our last day on earth. We are not youthful but we should feel brand new and share our experiences with the young ones. Today is Chinese New Year and Valentine's Day. I hope you have a good holiday.

46. Breast tumours in an old spayed cat

"Can I get some medicine for my cat?" the man came to Toa Payoh Vets and showed me a handphone picture of his 10-year-old cat with a large growth.

"Your cat appears to have breast tumours," I said. "No drugs can make them disappear. She needs surgery. What cream did you apply onto the tumours? Is she still eating?"

"I applied some antiseptic cream. My cat eats very little for the past 2 weeks," the man showed 1 cm width between his forefinger and thumb of his right hand.

What can be done now? Surgery would be the answer. There was the cost. More important this was a high-risk anaesthetic case as the cat had lost appetite for 2 weeks. Surprisingly, her temperature was normal. She was thin. I informed the owner that the cat could just die on the operating table due to her poor health. The pre-blood test was not done to save veterinary costs.

The following was done for this cat on the day she was admitted.

CONSULTATION. To enhance her survival chances, I injected baytril, anti-fever and anti-spasm drugs in 10 ml dextrose saline SC and had to decide whether to operate 2 hours later or wait till the next day. This was a difficult judgment. I decided to operate 2 hours later as the cat was not eating but her rectal temperature was normal. IV glucose was given first and continued during surgery.

PRE-ANAESTHETIC SEDATION Zoletil 50 @ 0.1 ml IV. The cat shot out a paw wanting to scratch my assistant Mr Saw when he put the Zoletil bottle noisily on the table. Today, Mr Saw seemed to be noisy. The cat had hissed at him before that. This was surprisingly as she did not behave similarly towards me and my second veterinary assistant Mr Goose.

"Maybe you are too noisy," I said. Mr Goose said as he grasped the scruff of the cat's neck and held the hind leg for IV injection of Zoletil. "Cats and rabbits at the preparation room for surgery get nervous when the place is noisy."

(In retrospect as I type this report at 5.46 am on Friday Feb 12, 2010, the cat could be defending herself from being given antiseptic ointment by her owner who had cleaned her breast tumours for some time. Her owner had a dark complexion like Mr Saw. This was one explanation as the cat associated Mr Saw with her owner and knew that she would be applied antiseptic ointment. It must be painful getting this application.)

Mr Goose pressed the medial side of the thigh to bring out a dark blue vein. Zoletil 0.1 ml IV is safe for this 2 kg cat. She was sedated. She had an IV glucose drip in her forearm prior to this sedation.

Gas mask isoflurane anaesthesia after this gave her freedom from pain during surgery. 3 minutes before the end of surgery, the isoflurane gas was cut off. The cat was given oxygen to breathe.

SURGERY
Two things to note:
1. The wound was very large as the tumours were scattered. Ensure sufficient skin to stitch up.
2. Bleeding from the superficial epigastric arteries (cranial around MG1 and MG2 and caudal around MG4 and MG5). Clamp the bleeding points and ligate.
3. Subcutaneous fat stitched to provide less tension for the skin.
4. Skin stitched.
5. Body wrapped. E-collar.

POST-OP CARE
The cat was very weak and slept. I checked her tongue at the end of surgery. It was bright pink as she had been given glucose IV. Glucose by IV drip is necessary for such cases to have a chance of survival under general anaesthetic. Continue IV drip of dextrose saline and Hartmann's solution over the next 24 hours.
Will the cat survive? It is hard to say. Goto: www.toapayohvets.com for updates.

TIPS FOR OLD OWNERS
This is a case where a spayed cat still gets breast tumours. Spaying reduces the incidence and most spayed cats and dogs don't get breast tumours.
It is a matter of probability rather than a guarantee that spaying will prevent mammary tumours in old age.

It is best to get breast tumours in cats and dogs removed by your vet when they are much smaller. It will be less costly. I can give a high discount for some cases with financial distress. I can't do it for every case as it is costly for the surgery and post-operation complications and nursing for the next 7-14 days. Big tumours of the mammary glands get ulcerated and infected. The cat would then stop eating and die a painful death.

45. Breast tumours in old dogs in Singapore

"Can spay be done together with the removal of sternal abscess?" the young man who brought in his old dog to the surgery as scheduled, on this bright Sunday May 18, 2008 morning asked.


"Sternal abscess" --- actually mastitis, now reduced after 2 weeks of antibiotics

"Yes, it can be done" I explained. "It is not good for the old dog as the anaesthetic time will be longer. The chances of the old dog dying on the operating table increases as the anaesthesia is prolonged. The spay itself takes around one hour."
"I thought it takes 30 minutes to spay a dog?" the young man must have done his home work and research.

"Yes, in some cases" I said but did not elaborate that his dog was a bit on the fat side and spay surgery would take longer. "The actual surgery can be as fast as 30 minutes from skin incision to last stitch of the skin if the vet can hook up the uterine horn at the first try.

"However, if you include the pre-operation shaving, scrubbing and anaesthetic gas given to get the dog to sleep, the whole spay takes more than 1 hour. In removing the sternal abscess, I need to pull skin from nearby areas, so it is not a simple stitching of just the wound left from removing the sternal abscess. This takes a lot of time, around 30 minutes or more. "

He nodded his head. Do one surgery at a time to avoid anaesthetic complications. Spay today. Then 2 weeks later, remove the mammary tumour and sternal abscess.

So, I started to time this spay surgery commenced at 10 am. The patient was not slim and had difficulty breathing, being a flat-faced Shih Tzu.

Procedure:
The dog was clipped at the preparation room. Then she was brought to operating room and given 8% gas to knock her down using a face mask. She struggled for 2 minutes and was asleep. This took around 15 minutes. She was then intubated with a breathing tube to connect her lungs to the gas machine, using a maintenance dose 2% gas until the last 3 stitches when the gas was reduced to 0%. Dog woke up within 2 minutes at end of anaesthesia. The four legs were stretched out tautly as I find this method enabled me to hook up the uterine horn much easier.


Gas anaesthesia is best and safe for old dogs. Do intubate all the time although gas mask can be used

The vet must check the anaesthetic settings systematically to ensure a smooth anaesthetic process

Surgery:
Incision to last stitch was 40 minutes actually.
I incised 1 cm from the umbilicus, making a 1-cm cut. The linea alba was identified after snipping off some subcutaneous fat. There was some bleeding but this was not serious.

I inserted the spay hook to fish out the left uterine horn. I slanted the hook 45 degrees from the horizon, put it into the abdomen to the right and downwards in the direction of the bladder. The hook skimmed over the surface the liver lobes.

Then I rotated the hook 90 degrees and pulled it out of the skin incision, hopefully with the left uterine horn. In slim female dogs, this was not a problem. But in this dog, I tried 8 times. Omental fat kept appearing in the hook. This was not good as the minutes passed quickly. In such cases, I switch to hooking the right uterine horn. One loop of pink intestine kept coming out in the hook. What to do? Persevered.

If the dog was slim, it would normally be easy for me to hook the left uterine horn with the left ovary after 1 or 2 tries. Fortunately, I caught the right uterine horn on the 3rd try. What a relief you would imagine.

But there was so much fat surrounding the right ovary. I could not fish it out with the right uterine horn. "Release the string's tension on front legs," I asked my assistant to loosen the strings."

Still, the ovary could not be hooked out. I knew I had to extend the skin and linea alba incision 0.5 cm cranially. This bigger incision was sufficient. I pulled out the right fat- enclosed ovary. I felt for the taut ovarian ligament with my left forefinger. A very tight ligament. The dog moved as the ovarian ligament was pulled.

"Increase gas to 5% for 30 seconds and then go back to 2%," I said to the assistant. This happened when the dog was just slightly under surgical anaesthesia and had not felt any pain till the ovarian ligament was pulled. Previously I used to pull this the ligament broke from its attachment. Nowadays, I used the scalpel to break it and continued ligating the ovarian stump.

I ligate the stump 2 times after placing 3 artery forceps clamps on the ovarian tissues cranial to the ovary. Now, the ovary could not be seen as it was enveloped inside a thick clump of fat. I had to estimate its position.

After ligation and incision of the ovarian fat, I lifted up the right uterine horn. The assistant had loosened the tension of the front legs. In some cases, I asked the assistant to put his hands under the shoulders and elevated the dog so that I could access the uterine horn easier. In this case, on pulling the right uterine horn, I could see the uterine body and the left uterine horn arising from there.

The same process of getting the ovarian ligament was repeated. Then the uterine body was clamped using the 3-forcep technique as for the ovarian tissue. 2 ligations were used.

3/0 absorbable sutures did not feel strong enough compared to 2/0 but was used in this dog. I closed the muscle layer with 3 simple interrupted sutures placed a good 5 mm away from the muscle edge. If you place it too close, the suture might break down and you would get a hernia.

Reduce gas to 0% before after closing the muscle layer. Dog wakes up as the last skin stitch is placed
It would be best not to use continuous sutures to close the muscle layer unless you are very confident of your suture placement. Otherwise one too close to the muscle edge stitch may burst open. The whole stitching breaks down and there would be a lump. Also, I do not use continuous subcutaneous suture as advised in some veterinary surgery books. They cause more irritation and may break down. I used 2 horizontal mattress sutures to close up the skin incision. One packet of suture was fully used in this case. In bigger sized dogs, 2 packets may be needed. Around 2 cotton swabs would be used as there was little bleeding.

12-year-old Shih Tzu 7.7 kg, 38.4 deg before spay. Large mammary tumours (X). First skin incision to last skin stitch took 40 minutes in this case as the first time hooking did not fish out the uterine horn.
Carprofen a non-steroidal anti-inflammatory injection 0.5 ml was given to prevent pain and swelling. Antibiotics given. The dog went home in the evening after sufficient rest at the surgery. Do not send the dog home immediately even if the owner wanted to do so as the dog needed time to be stable after anaesthesia.

NEXT STAGE
Spay was advised first to remove the female hormone production by the ovaries. Once deprived of the hormones, it was hoped that the breast tumours would not grow so aggressively. 2 weeks later, the breast tumour and the sternal abscess would be removed, hopefully without any anaesthetic complications and death.

CONCLUSION
Can this dog survive the anaesthesia the second time? Nobody can guarantee survival under general anaesthesia. In any case, never attempt to spay and remove breast tumours in one surgery as the vet prolongs anaesthesia time. Every second that the dog is under anaesthesia, his or her heart may fail. So, it is best to do one surgery at a time to minimise the risk.

UPDATE AS AT FEB 11, 2010
The owner did not return to Toa Payoh Vets for surgery nor follow up. Spaying the dog when she was young would be ideal as breast tumours seldom occur in spayed female dogs. This is not to say that spayed female dogs don't get breast tumours but the probability of them getting such tumours are much lower.

44. Medial entropion surgery in the Shih Tzu

Saturday Feb 6, 2010 was my day off. However, a person wanted a meeting. So, I was flexible and took the time to meet the 3 young vets and had an interesting discussion with them and at the same time educate myself regarding the veterinary industry and trends.

One of the problems of young vets is the prospective clients' remark: "You look so young...can you perform the surgery (e.g.repair the bite wounds)?"

Well, this is a common remark and applies even to medical surgeons. Last year, I was at the Singapore General Hospital for an operation to be done by Dr Foo Chee Liam, an experienced surgeon in his late 50s and an old friend. All prospective patients will be comforted by the appearance of his grey hairs. They testify to his abundant surgical experience over the years.

His assistant, a young surgeon known as "The Registrar" attended to me in the administrative matters. I asked her how's her posting as we walked to another section to make the booking and she said to me: "Singaporeans look at me and query whether I am capable of doing their operation." I was not surprised at her comments as Singaporeans say the same thing to newly minted veterinary surgeons too.

How should one reply to such queries? It will be difficult unless one is a show man and produce testimonials. The business of surgery is serious and is not a theatre. I guess, the young ones who don't have senior vets in the practice have to take such remarks in their stride and assure the prospective client that his dog is in good hands. "Such remarks are made about the young vets in established vet practices in Singapore," I told the 3 young vets. "All vets will have to go through such challenging remarks."

Other than real people in this real world, is there another invisible world supervising us? I ask this question because I had this 10-year-old Shih Tzu with corneal ulcers, acute conjunctivitis and pus in his left eye. A 1-year-old Shih Tzu had come in 3 days ago for medial entropion surgery. This 10-year-old Shih Tzu was my answer to "what happens if there was no medial entropion surgery done for the Shih Tzu?" Where can I get a recent photograph to illustrate my medial entropion surgery?

Well, you can call it a coincidence. I have had 3 Shih Tzus recently. But the 10-year-old Shih Tzu was presented with corneal ulcerations and black eye bags due to many years of irritation from excessive tear production and rubbing of the eyes. All these could be avoided if the owner had got a medial canthoplasty and nasal fold excision. "I don't know there is such a surgery," the lady owner told me. It is a surgery seldom mentioned by vets in any case.

The following pictures explain the surgery. Goto www.toapayohvets.com for the pictures.

http://www.bekindtopets.com/dogs/20100153Medial_Entropion_Shih_Tzu_ToaPayohVets.htm

43. Blood in the urine of an older male dog

"Around 8 months ago, Vet 1 checked the bladder with his hand and said that he could feel no urinary stones," the young man said to me. "So he prescribed medication. My dog stopped passing blood in the urine for 2 months only."

"Why didn't Vet 1 X-ray the dog?" I asked. The young man who wanted to be a Food and Beverage entrepreneur said, "Vet 1 felt the bladder and since there was no stones, there was no need to X-ray the bladder. He even refer me to Vet 2 who had better X-ray and equipment." Vet 1's X-rays did give erratic quality and that might be why he did not take the X-ray. Most likely, to remain price-competitive with Vet 2, he would rather not increase his fees due to X-ray charges.

This amenable young man was a good conversationalist. He joked with me, pointing to his tummy and saying: "I enjoy eating food as you can see." Yes, I could see he looked very much like a successful chef with the proportions and size to prove he loves good food.

The owner then sought a second opinion from Vet 2.
"Vet 2 did an ultrasound scan and said there were no urinary stones. I got the medication and the dog stopped passing blood in the urine for 2 months. So, I asked Vet 2 to do an X-ray and there were urinary stones."

"why didn't you ask Vet 2 perform the operation?" I guessed the vet fees would be it more expensive as it was a much bigger set up with vets. Price has always been important in this period of recession and job losses.

But the young man said: "Two of my dogs died at Vet 2. One of them was old. The other one died on the operating table. So, I do not want my dog to be operated there."

This survey showed that this dog owner does not forgive or forget the death of his dog on the operating table. All vets will get pet deaths on the operating table as not all surgical cases are in excellent health.


Urinary sand and stones in the bladder and penile urethra. Actual stones are placed on top of the X-ray for comparison
Abundant fine urinary sand is found in the bladder during surgery. The sand can be seen on X-ray but it is not so clear


Day 2 after removal of urinary stones
Well-formed sharp urinary stones inside the penile urethra
I did this survey to help me understand the owner's point of view as many owners do hop between vets. Dogs are family members and a large number of dog owners in Singapore and all over the world is very worried about deaths during anaesthesia. This survey shows that the owner never really forgives such episodes.

Fortunately, the old dog operated by my Associate Dr Jason Teo was much alive during and after the surgery. Otherwise it would be another black list in this young man's book of vets to avoid.

VETERINARY TIP
In retrospect, during the surgery in Feb 2010, this old dog had abundant amount of urinary sand inside the bladder. This urinary calculi was obvious in the excellent X-ray taken by Vet 2 but the contrast using air inside the bladder could not be made due to large obstruction by stones in the penile urethra. Bladder palpation will not reveal the presence of urinary sand.

More info about this case is at:
Urinary stones. Which surgical approach?








I did this survey to help me understand the owner's point of view which is so much different from the vet's point of view. Dogs are family members and a large number of dog owners in Singapore and all over the world is very worried about deaths during anaesthesia