A 6 years old female pug whose owner called us initially at approximately 2:00 am. According to her owner, she had been panting for 4 hours, and whelping for 2h without successfully producing any puppy, and now she was showing signs of tiredness. Her owner was concerned there was some vulva discharge (read more).
The bitch had two previous litters without any of the issues she was having this time, and wanted some phone advice as to what she could do at home. Because the bitch was still pushing, I advised the owner to keep her in a quiet place, not to stress her to prevent any dystocia, and close monitoring if there was any progress. In case no puppy were produced in half an hour, my advice was to bring her down to us for an examination. We agreed the owner would call us back in half hour if the problem persisted, in which case she might need either some medical treatment help or a caesarean.
We received a second called about 30 minutes later. Mrs Adams was even more
concerned now. On her last pregnancy, her dog needed some medical treatment (oxytocin, according to the owner), and the last foetus was a giant puppy. On this ocasion she was mated several times, and she is not pushing so much now. At this stage I did recommend to bring her to us as soon as possible. Cost and estimations were briefly mentioned over the phone at this stage, to which the owner agreed.
On arrival the bitch was very heavily pregnant and distressed, although ambulatory. On her clinical examination her mucose membranes were pink, with a capillar refill time under 1 second, her heart rate was 152 bits per minute, and she was panting. I noted her temperature was normal-low. On vaginal palpation I checked that he cervix was dilated enough to allow a foetus to pass. However I was not able to check how dilated it was due to the foetal and placental position. She was not presenting Ferguson’s reflex, and on external foetal manipulation, I could not deliver a puppy. In effect there was some green discharge and placental tissue protruding, but blood dripping from her vulva.
After a long discussion of all the options (medical treatment, surgical approach,
further investigation -scanning, x-rays- ) I mentioned that I would be more concerned for the puppies’ heart rate, as a lower rate would be a sign of foetal distress. The owner accepted ultrasound, to rule in or out any foetal distress, necrotic foetus, a possible internal bleeding or uterine rupture with abdominal free fluid, to help making a decision. On untrasound it is confirmed that there are, at least, four puppies alive, stressing that scanning is not a reliable technique to count puppies, as her onwer requested, and radiography at this stage would give more accurate figure. I also stressed to Mrs Adams that the smaller the litter, the bigger each puppy is likely to be, and that can be an issue for successful whelping. It was also noticed that the heart rate of 2 puppies were under 200 bits per minute, which was consistent with foetal stress and risks of foetal death. Meanwhile we did not see the bitch pushing or whelping at any moment while the scanning was performed.
Although I offered medical treatment to the owner, I informed Mrs Adams that that the uterine stimulation with calcium and oxytocin was unlikely to work in
this case, and my best advice was caesarean for two reasons: it was cruel leaving her in pain knowing it was very unlikely she would naturally whelp
successfully because of the lack of Ferguson’s reflex, and there was signs of foetal stress present, that can potentially be life-threatening for litter.
At that stage the owner was very concerned about the surgical approach, and needed some time to consider all the options. Therefore the nurse, and I took the bitch to the oxygen cage, and placed an intravenous catheter, giving the owner some time to discuss the situation with her friend, who had accompanied her. At all times, the pros and cons for the different options were discussed, along with their estimation. Meanwhile the bitch became much calmer, sat down, and stopped panting. Finally, they opted for the option I had recommended for the dog (caesarean). I informed her that most of the drugs needed to perform the surgery are not licensed for this condition, and risks are unknown. The owner was given an off-license consent form, which she read thoroughly and signed.
While I was preparing the fluid therapy for the procedure, the veterinary nurse asked me to discuss with the owner about the fees and the need to pay a deposit in advanced, as it is routine practice policy. Once we have a final figure, any difference would be refunded. However, the onwer understood the cost could be sorted out after any treatment was given. At this stage, we offer to listen to the recorded phone call again, as I disaggreed with the conversation as it was remembered by the owner.
There was also some discussion as to what extend the owner understood I could break the practice policy at my discretion, given the situation that the manager was not available at that moment. Due to the risks for the foetuses, the bitch was stabilized by keeping her in an oxygen cage, without any pain relief, while both parts were discussing the finantial situation.
The owner agreed with the given estimation once explained, we agreed with initiating the caesarian to reduce risks and inneccessary suffering, while the owner would collect the payment from her safe box at home. By then we were close to 4:00am, and the owner was concerned she would not be fit to drive her children to school by 8:00h if she had to come back to our practice sooner, offering to sort out any payment after 9:00am. After we stressed that the deposit needed to be sorted out prior to any treatment other than first aid and pain relief, the owner understood that we were being unreasonable, given her situation at home, and changed her mind in regards to surgical treatment, declining the two options already discussed.
Up until now the options proposed to the onwer were either medical or surgical. Both the vet nurse and I were reluctant to perform an euthanasia due to finantial restrictions and practice policy. However, I suggested this third option, on animal welfare grounds, that for my own ethical belief I had not offered yet. The owner was strongly against this option, and the discussion of this option alienated both onwer and her friend from the veterinary nurse and I, despite we all agreed that euthanasia was the least desirable option. Given the situation, I offered the owner requesting a second opinion from another veterinary surgeon, and discharging against veterinary advice in writen. While still on our waiting room, the owner contacted another colleague who was on call and agreed with taking the case straight away. They booked an appointment for 4:30am.
After reading and signing the “discharge against vet advice” consent form, the intravenous catheter was removed from the bitch’s vein, on Health and Safety grounds. At this point the owner has also declined signing the “off-licensed consent form” and any other treatment.
On a last clinical examination before leaving our premises, the bitch was quiet, alert and bright, with a respiratory rate of 48 breath per minute, neither panting nor whelping. They left our practice by 3:45am
On a follow-up, a member of our team contacted the colleague who took over our case. I was informed a caesarean was performed some hours later at another practice, producing two healthy puppies and two dead foetuses. The bitch was in good health as well.
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