Common Postpartum Problems in the Bitch: Control & Prevention

January 12, 2022

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Postpartum Problems in the Bitch

DR. ROHIT RAJ, CANINE SPECIALIST,KOLKATA

It is considered normal for bitches to have vaginal discharge for up to 3 to 5 weeks after whelping. The discharge (called lochia), immediately postpartum, is very noticeable because of its green color due to the presence of uteroverdin (iron pigment) at the edges of the placental attachments. Unless there are complications, this should change to a reddish-brown to green mucoid discharge within 12 hours. Normal uterine involution and repair may occur for up to 16 weeks post-whelping. Bitches body temperature may be mildly increased (up to 103 degrees) postpartum, due to normal inflammation associated with whelping. Their temperature generally returns to normal (99 to 102) within 24 to 48 hours. If bitches have had a cesarean section, their temperature elevation may be elevated due to post-surgical inflammation. Elevations in temperature need to be monitored, and may indicate some pathology in the bitch. Mammary glands should be symmetrical and moderately firm with no palpable firm masses, redness or heat. Milk should be easily expressed from several openings at the end of each nipple. Normal colostrum may be deep yellow to light yellow in color and from thick to thin in consistency. Colostrum is only produced for the first 18 to 24 hours post-whelping. Normal milk may be white to grayish in color and is of watery consistency. Any changes from these normal observations may be indicative of problems and need to be assessed by your veterinarian.

Canine post-partum problems are comparatively less frequent and different from other domestic animals. The parturition is prolonged in the bitch (second stage of labor sometimes requiring up to 24 hours) hence the first thing a clinician must look for is the presence of any fetus. In canines, normal postpartum discharge is dark green or greenish black in colour for the first 1 to 2 days which then becomes bloody and persists for 1 or 2 weeks or even up to 1 month. There is usually a lot of discharge for the first 5 to 7 days. It should gradually decrease in volume and become thick and clear or grey by day 10.

During the first few days of taking care of the bitch after whelping:

Make sure she is eating and drinking well.
Keep her hind end clean, as there will be discharge for a while.
Go outside with her to make sure that she is urinating and defecating normally.
Diarrhea is common after whelping, and a probiotic supplement may help.
Once the puppies start nursing vigorously, the mother’s appetite usually increases significantly.
Lactation is the greatest energy demand a dog will every experience. Palpate over the bitch’s ribs regularly to check her weight. You should be able to feel them easily, but not see them easily.

Most health problems occur in the first few weeks after the birth. Monitor the mother carefully, take her temperature if she seems “off” at all, and call the vet if something just doesn’t seem right. The three most common health problems after whelping are metritis, ecalmpsia and mastitis.

Retained Placenta

Retained placenta is an extremely uncommon postpartum problem in the bitch. Detachment and passage of the placenta usually occurs with the birth of each puppy or within approximately 15 minutes of delivery. The most difficult aspect of this problem is accurately diagnosing it. Owners often attempt to count placentas as they are passed. With the confusion and excitement associated with observing each puppy’s delivery, we often fail to see how quickly the dam may consume a placenta. True failure to expel a placenta is reported most commonly in toy breed dogs. Definitive diagnoses are almost impossible as the retained placentas degenerate, and are passed in the normal postpartum discharge. If the bitch has live puppies that are nursing, she is producing oxytocin which leads to uterine contractions and should allow for the normal expulsion of this tissue.

Retained placenta(s) can lead to uterine infection (metritis), which can result in the bitch becoming quite ill (see below).

Metritis

Metritis is a serious condition and is often times confused with pyometra.

Metritis generally refers to infection of the uterus after whelping when progesterone levels are low. We refer to pyometra when we discuss uterine infections that occur when the uterus is under the influence of progesterone.

Progesterone levels are elevated from the time of the LH surge, and remain elevated for approximately 65 days, in the pregnant bitch, before returning to a baseline. Acute infection of the endometrium (lining of the uterus) should be suspected if lethargy, anorexia, decreased lactation, fever, and odiferous vaginal discharge are noted. The bacterial infection is usually due to ascending infection from the lower genitourinary tract. This infection may be preceded by dystocia, retained fetuses or placentas, or from contaminated obstetrical manipulations.

Rapid diagnosis of metritis is important for the bitch’s health and her future reproductive capacity. Changes in blood work (biochemical changes) usually reflect septicemia (bacteria in the bloodstream), inflammatory reactions, and endotoxemia. This can be represented by either increased or decreased white blood count +/- anemia, increased or decreased protein levels, signs of dehydration, or elevations in kidney and liver enzymes. Vaginal cytology reveals a hemorrhagic to purulent (pus-like with white blood cells and bacteria) discharge. Abdominal ultrasonography may reveal retained placentas or fetuses, mummies, or a fluid distended and/or thickened uterus. Vaginal culture and antibiotic sensitivity testing should be done for both aerobic and anaerobic bacteria. Collection for the culture should be with a guarded culture swab and taken from the anterior or upper portion of the vagina as close to the cervical opening as possible.

Medical management should include intravenous fluids with appropriate electrolyte evaluation and supplementation, and broad-spectrum antibiotic administration. Ovariohysterectomy may be indicated depending on the bitch’s condition and her response to medical management. Treatment with oxytocin for 3 to 5 days will help to evacuate the uterus of discharge. Use of prostaglandin F2-alpha (PGF2α), to evacuate the uterus, requires care and close observation since the infected uterus may be friable or damaged and could perforate or rupture with this medication. Additionally, the septic bitch may develop respiratory distress, a drop in blood pressure, or collapse with the use of PGF2α. Metritis can result in a chronic endometritis and can affect future fertility.

Uterine Prolapse

Uterine prolapse is a very uncommon occurrence in dogs as a complication of parturition. Prolapse is the protrusion of part or all of the uterine horns and body through the vulvar lips. The diagnosis is based on palpitation of a firm tubular mass, protruding from the vulva postpartum, and an inability to identify the uterus with abdominal ultrasonography. Replacement should be attempted as soon as possible, because the longer the tissue is exposed, the more likely that severe edema (swelling), tissue infection, and necrosis (tissue injury) will occur. The prolapsed uterine tissues are at risk for damage and infection as a result of exposure and contamination.

When the uterine tissue is healthy, repositioning in the abdomen may be attempted. However, the size of most bitches and swelling of the uterine tissue resulting from the diminished blood flow out of the prolapsed tissue usually prohibits manual replacement alone. Typically, a combination of manual external reduction combined with abdominal repositioning through a ventral midline incision is needed to replace a prolapse. Sterile lubricant is applied liberally to the exposed tissue while the animal is being stabilized and anesthetized to prevent further trauma to the tissues. The prolapsed uterine horn(s) is flushed with sterile saline under pressure. Manitol, hypertonic saline, or dextrose solution can be used to reduce edema if necessary before attempting reduction. Once the uterus is replaced, care should be taken to fully evert the tips of both horns and then the animal should be given 1 to 2 units of oxytocin to cause uterine contraction and prevent re-prolapse. If the uterus remains in place for 24 hours, the risk of re- prolapse is unlikely because the cervix begins to close. If the tissue is damaged or necrotic, an ovariohysterectomy is recommended. In some cases, reduction is impossible due to extreme engorgement or necrosis of the prolapsed tissue. In these cases, the external segment can be amputated followed by ovariohysterectomy. The prognosis for future fertility and chance of reoccurrence are undefined.

Subinvolution of Placental Sites

During formation of the placenta, the cells from the developing embryo invade into the uterine wall. After the placentas detach post-whelping, the placental sites normally heal (involute) by sloughing these invading cells (syncytial trophoblast cells). In some cases, however, these cells continue to invade into the uterine wall, resulting in continued hemorrhage from the placental sites. This condition is termed subinvolution of the placental sites (SIPS).

The condition is clinically detected by the presence of serosanguineous (yellowish-red) to hemorrhagic vaginal discharge beyond 4-5 weeks postpartum. The normal uterus continues to involute and repair itself for a period of up to 16 weeks. The cause of SIPS is unknown, and generally infection is not present.

Fertility is maintained and blood loss is minimal.

Treatment is generally not necessary, recovery is spontaneous and the symptoms are usually mild. On rare occasions, bleeding may be sufficiently heavy to result in significant anemia. When vaginal bleeding is copious other causes need to be investigated such as clotting disorders, trauma, neoplasia of the genitourinary tract, or normal proestrus. Diagnostics include vaginal cytology, vaginoscopy, coagulation testing, ultrasound, and radiographs (x-rays) to aid in determining the cause or source of bleeding. Definitive diagnosis requires biopsy of the placental sites, however, this is rarely necessary. Vaginal cytology is often diagnostic for SIPS if syncytial trophoblast cells are visible more than 4 weeks after delivery. Cytology in dogs with SIPS contain only a few white blood cells.

Ultrasonography can also be used to diagnose the condition when placental sites are still readily visible beyond 4 weeks postpartum. On rare occasions, bitches may hemorrhage significantly and require blood transfusions or an ovariohysterectomy as a life-saving measure.

Mastitis

Mastitis is an acute or chronic infection of the mammary gland involving one or multiple mammary glands. The most common organisms involved are those of the skin. As puppies nurse and pull, or bite the teats, environmental bacteria can gain entry to the skin and mammary glands. Infection may also be from hematogenous (from the bloodstream) sources as well. One or more glands may be affected and are red, firm, warm, and painful to the touch. The bitch may exhibit varying degrees of pain, be neglectful of the puppies, become lethargic, febrile, have decreased appetite, and not allow proper nursing by the puppies. Milk from the affected glands is often discolored (red, brown, or green) due to the presence of red and white blood cells and is generally thicker than normal milk.

Abscesses may develop and be seen and palpated as bulging, firm spots over which the skin is discolored and may rupture.

Milk from these glands will contain white blood cells and bacteria and the secretions should be submitted for culture and be evaluated by cytology.

Antibiotic therapy should be started based on cytology results and adjusted accordingly to the culture if necessary. Penicillin or cephalosporin’s are a good choice for empirical treatment until culture results are returned. Using hot compresses or whirlpool therapy of the affected gland(s) and manual gentle stripping of milk out of the affected gland(s) is helpful.

There is no evidence that nursing from the affected glands is problematic for the puppies, but they will tend to avoid glands from which it is difficult to obtain milk. If abscessation is present or culture results indicate antibiotics that are unsafe for the nursing puppies, it may be necessary to wean.

Severe abscessation and necrosis may warrant mastectomy and aggressive wound management. Occasionally, bitches will develop mastitis on subsequent lactations. This may be due to some anatomic feature of their mammary glands that allows for bacterial invasion. Antiprolactin therapy (cabergoline or bromocriptine given orally twice daily) may be indicated in severe cases to reduce lactation. Early detection and treatment is optimal, rather than prophylactic antibiotics, which tend to favor resistant organisms.

Agalactia

Agalactia is defined as a failure to produce milk. While uncommon, primary agalactia is a lack of mammary development during gestation, which, results in inadequate milk production. This is a commonly recognized adverse effect of progesterone supplementation during pregnancy. Secondary agalactia is more common, and is a lack of milk available due to a failure of milk letdown into the mammary chain. Mammary development is present but milk cannot be readily expressed through the teat sphincter. Agalactia can occur secondary to premature parturition, malnutrition, severe stress, metritis, mastitis, or other illness.

Once noted, treatment includes providing supplementation to the puppies while continuing to allow suckling, which promotes milk ejection. It is important to provide optimal levels of nutrition and adequate water to the dam and resolve any underlying disease. If detected early, milk letdown can often be induced pharmacologically. Mini doses of oxytocin (0.25 to 1 units per injection) are given subcutaneously every 2 hours. Puppies should be placed on the bitch immediately following oxytocin administration to promote milk letdown.

Metoclopramide orally, subcutaneously, or intravenously, can be given every 12 hours (dopamine antagonist) to promote milk production.

Metoclopramide may have unwanted neurological side effects after multiple doses. Alternatively, domperidone (another dopamine antagonist) can be given orally to increase milk production with minimal to no side effects. Therapy with either medication is usually rewarding within 24 hours. If acceptable results are not achieved, hand rearing of the puppies is necessary. Bitches with poor milk production resulting from low concentrations of either prolactin or oxytocin may exhibit poor mothering behavior. A bitch that fails to produce milk during one pregnancy is likely to have a similar problem on subsequent pregnancies and should be considered for removal from the breeding program.

Galactostasis (Stagnant Milk)

Galactostasis (build up of milk) can cause engorgement and edema of the mammary glands with associated discomfort. This makes further nursing less likely due to unwillingness to allow the puppies to nurse and the problem becomes self-perpetuating. Galactostasis may occur secondary to inverted or imperforated teats, litter loss, failure to rotate nursing puppies, small litter size or occasionally from pseudocyesis (false pregnancy). This accumulation of milk may predispose the bitch to mastitis. In bitches who have lost their litter or have false pregnancy, cabergoline or bromocriptine orally twice daily for 2 to 4 days may be helpful.

Eclampsia

Eclampsia or puerperal tetany is a result of low concentrations of calcium in the body. This should not be confused with preeclampsia in women, a syndrome of high blood pressure and protein loss that occurs during late pregnancy. In dogs, this is usually noted during the first 4 weeks (at peak lactation) postpartum, but can occur in the last few weeks of gestation.

Eclampsia can be life-threatening and is predisposed by improper prenatal nutrition, inappropriate calcium supplementation, and heavy lactation demands. This is most common in small breed dogs nursing large litters, and is more likely if the ratio of body weight to litter size is small. Excessive prenatal calcium supplementation can interfere with the physiologic mechanisms to mobilize adequate calcium stores and utilize dietary calcium sources. It is best to feed a balanced growth or puppy formula commercial diet without additional vitamins or mineral supplementation during the second half of gestation and throughout lactation. Supplementation with cottage cheese or other dairy products should be avoided as it may disrupt normal calcium-phosphorus-magnesium balance in the diet.

Although the onset of clinical signs of eclampsia is most common at peak lactation, hypocalcaemia may develop during late pregnancy or at whelping.

Initial clinical symptoms may include behavioral changes, salivation, stiffness or limb pain, ataxia, hyperthermia, and rapid heart rate. Bitches may be neglectful of the puppies, restless, or exhibit scratching at the face. This may be followed by a wobbly gait, dilated pupils, disorientation, and tremors. Symptoms may progress to the development of tonic-clonic muscle contractions or seizures.

Immediate medical intervention should be instituted with slow intravenous infusion of 10% calcium gluconate given to effect. Close cardiac monitoring (by use of electrocardiogram) for bradycardia (slowing of the heart rate) and arrhythmias (abnormal heart rhythm) is required. Uncontrolled seizures may lead to cerebral (brain) edema. Barbiturates or diazepam (1 to 5mg intravenously) may be indicated. Mannitol may be indicated for cerebral inflammation and swelling. Corticosteroids are undesirable because they may further decrease calcium levels. Blood glucose levels should be monitored and treated if they fall. Hyperthermia from seizure activity should be treated if necessary. Once neurological signs are controlled a subcutaneous infusion of equal volumes of calcium gluconate and 0.9% saline solution is given repeatedly every 6 to 8 hours until the dam is stable enough to take oral supplementation.

It may be beneficial to remove the puppies from the bitch for 12 to 24 hours. If response to therapy is prompt, nursing may be gradually reinstituted until the puppies can be safely weaned. If clinical signs recur once the puppies resume nursing, they must be removed and hand-fed or weaned. Eclampsia may recur at a subsequent lactation. It may be prevented by feeding a well-balanced diet during pregnancy, without calcium supplementation. In bitches with a history of recurrent eclampsia, calcium carbonate (500 to 4000 mg/dam/day divided) may be given throughout lactation. Each 500 mg calcium carbonate tablet (TUMS, regular strength) supplies 200mg of calcium. It is better to wait to supplement calcium orally until at or after whelping, rather than during pregnancy as over supplementation during pregnancy may result in uterine inertia (failure of the uterine muscle to contract adequately during labor).

Postpartum Behavior

Dog owners often seek professional advice concerning what is normal behavior for bitches after whelping and for the treatment of abnormal or undesirable aspects of maternal behavior. Maternal behavior is so important for the survival of offspring that evolutionary forces have programmed the brain circuitry to aid with puppy survival. Due to our involvement during delivery, cleaning and resuscitation of newborns, supplemental bottle or tube feeding, and assistance in weaning onto solid food, we have likely facilitated survival and reproduction of some mothers with defects in their maternal programming. Some dogs exhibit complete and effective maternal behavior while others would have few, if any, surviving offspring without our assistance.

With major physiologic changes occurring at the time of birth, along with the overwhelming presence of demanding puppies, it is somewhat surprising that females remain as calm as they do during this post-whelping period. It has been found that stressful physical stimuli produce a smaller adrenocortical response in lactating females. Rather than responding to threatening stimuli with excitement, the dams are induced to remain calm and continue to care for their young. In a wild setting, this may put the mother’s own safety in jeopardy, but the mechanism prevents disruption of her care at this critical time.

If the dam becomes excessively nervous after whelping, this may lead to her attacking her own offspring. Killing and consuming any part of the dead newborn is considered cannibalism. This has been proven in other species to adjust the litter size in accordance with environmental or nutritional conditions (low protein diets). So as wild animals, this may be regarded as a normal aspect of maternal behavior. Cannibalism may also be considered to be related to lack of maternal experience, immaturity of the dam, illness of the newborns, or environmental disturbances. For example, a sickly puppy may harbor disease organisms that could affect the remainder of the litter. Bitches may often sense physical abnormalities in the young that trigger the attack. This may include low body temperature, lack of movement, or some other reason not obvious to us. Her rejection may include cannibalizing the young, shoving it out of the whelping box, burying it, or hiding it from the remaining litter. In nature, this would minimize the attraction of predators to the other young and aids the bitch in avoiding wasting energy resources needed to care for these unhealthy puppies.

Overzealous cleaning of the newborn may lead to chewing into the abdominal cavity while she is trying to shorten the umbilical cord. Hormonal factors may incite this response as well. Placentas produce appreciable amount of progesterone during pregnancy, but this level falls abruptly at parturition with the detachment and expulsion of the placenta(s). Progesterone has a calming effect on bitches so its declining levels may precipitate irritability and aggression toward her young. Some bitches may excessively lick and carry their puppies around. Using a DAP plug-in (Dog Appeasing Pheromone) device may be helpful in calming the mother.

In rats, it has been proven that small litter size may not provide enough stimulation to the mother to maintain satisfactory maternal behavior to her young. This may apply to dogs as well in that a bitch with a singleton may not be able to leave the puppy alone so it can rest. Very large litter size may also be stressful to the dam. These bitches may seem anxious, vocalize and have difficulty settling down because they are obsessing over puppies crawling away from the group or due to the number of puppies for which them must care. Maternal indifference may also be a result of domestication and our continued involvement in the entire whelping and raising of our puppies.

Another important concern that is believed to create aggressive behavior toward people or puppies is a low calcium level. Calcium is needed for oxytocin uptake, which is needed for normal maternal bonding and imprinting on the young. Bitches with low calcium levels will often get glassy-eyed, stare and growl at pups, try to hide in small places or closets, or be disruptive and continually move puppies around. Often these bitches do not respond normally to their owners either. When monitoring calcium levels, one must monitor ionized calcium levels. Total calcium levels have been shown to be normal in association with calcium-responsive maternal aggression in Bull Terriers.

Bitches may dramatically improve within 30 to 45 minutes of calcium administration.

Hyperexcitement, failure to allow nursing, or other behavior may also be seen after Cesarean section. This may be secondary to pain response or from lack of recognition of the offspring. Maiden bitches that have never whelped before may not react positively toward their offspring when presented with their litter after surgical recovery. It may take up to 72 hours post-whelping for some bitches to exhibit normal maternal behavior. Close observation of the bitch and puppies during this time period is critical. When bitches are uncomfortable or in pain it is common to see unusual behavior. Proper nutrition, environmental conditions (temperature and quiet surroundings) and close human observation or intervention are necessary for a successful puppy raising experience.

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