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Caesarean Sections Part 3: Selection of premedication protocols.


In this third instalment we explore the implications of premedication for the Caesarean section patient.

As discussed in previous instalments, the aims of C-sections are to minimise the time from anaesthetic induction to delivery, have neonates with high Apgar scores and a dam that recovers quickly to permit prompt suckling and mother-offspring bonding



The majority of drugs that cross the blood-brain barrier e.g. sedatives, analgesics, induction and maintenance agents, also cross the placenta to potentially affect the neonates (Von Heimendahl & Cariou, 2009; Robertson, 2016). To reduce the depressant effects of drugs on both the dam and the offspring the selected drugs should ideally:

• Have a short duration of action

• Have minimal physiological effects 

• Be antagonisable wherever possible

(Murrell, 2016)


The increased progesterone of pregnancy and its metabolites positively affect the GABAA receptor, the site of action of many drugs used in anaesthesia.  Both progesterone and oestrogen have antinociceptive activity therefore:

• Reduce doses of anaesthetic related drugs by 25-40%.  

• Use the lowest feasible dose

• Administer to effect wherever possible

(Please see Caesarean sections: Part 1: Physiology of the pregnant patient, for further details)


Although premedicants may reduce the dose requirements of other CNS depressant drugs e.g. induction and maintenance agents, reduce patient anxiety, provide analgesia and reduce the dose of induction and maintenance agents, most of these drugs cross the placenta to potentially affect the neonate.  However, untreated pain may also affect the offspring as a result of uterine vasoconstriction and reduced foetal blood flow.  Therefore, the requirement for premedication should be carefully considered following assessment of the physical status of the dam, her amenability to handling, the availability and knowledge of premedicants (Von Heimendahl & Cariou 2009), and whether the procedure is elective or an emergency (Claude & Meyer, 2016). 

Although there are concerns about placental transfer of parenterally administered opioids (see later), some form of pre-emptive analgesia should be considered and local anaesthesia should be contemplated in all cases. (Please see Caesarean sections. Part 5: Maintenance of anaesthesia, monitoring, locoregional anaesthesia, recovery and analgesia)

In the absence of a marketing authorisation for the use of many premedicants in pregnant or lactating animals it is the responsibility of the veterinary surgeon accountable for the patient to assess clinical need & the suitability of the product, and use it in accordance with the prescribing cascade.  Further details may be found here.


The protocol of choice of many anaesthetists and general practitioners (Clarke et al., 2013).

Advantages and disadvantages

• Eliminates the effects of premedicant drugs on the neonates.  

• But: 

o No maternal analgesia prior to induction 

o No dose sparing effects on other anaesthetic agents

Most premedicant sedatives & analgesics are not specifically licenced for use in pregnant animals, and some e.g. buprenorphine, are expressly contraindicated prior to delivery of the neonates (Claude & Meyer, 2016). The specific wording of SPCs regarding use during pregnancy and lactation should be carefully assessed.  

Analgesia provision

Caesarean section is a major surgical intervention and analgesia should not be withheld.  Therefore, if no premedication has been provided, local anaesthetic techniques should be performed, and many anaesthetists administer analgesics once the last neonate has been delivered as the dam is, in effect, no longer pregnant at this point (Claude & Meyer, 2016; Murrell, 2016). (See Caesarean sections. Part 5: Maintenance of anaesthesia, monitoring, locoregional anaesthesia, recovery and analgesia)


Advantages of full mu agonist opioids:

• Provide a degree of preoperative sedation 

• Provide peri-operative analgesia to the dam

• Have minimal cardiovascular depressive effects

• Are dose sparing for other CNS depressants e.g. inhalation agents, resulting in more stable haemodynamic parameters (Claude & Meyer, 2016).


• Respiratory depression may occur requiring ventilatory support (Von Heimendahl & Cariou, 2009). 

• Foetal hypoxia possible following drug-induced maternal respiratory depression in an animal with already compromised respiratory function (20% decrease in FRC) as a result of the physiological changes of pregnancy (Murrell, 2016). (See Caesarean sections. Part 1: Physiology of the pregnant patient).

Antagonism of full mu opioids

With naloxone in both the dam and the delivered neonates (Clarke et al, 2013). 

The duration of action of naloxone is less than 1 hour, whereas methadone has an average duration of effect of 2-4 hours (Kushnir & Epstein, 2013). Repeat dosing of naloxone may be necessary and the period of effect of both the opioid and naloxone should be continuously monitored (Dugdale, 2010). 

Antagonization of undesirable opioid side-effects will also antagonise the analgesic effects. Alternative forms of pain relief should be considered.


Buprenorphine is contraindicated prior to delivery of pups.


PHENOTHIAZINES (e.g. acepromazine)

Not generally a suitable choice for C-section premedication.  

• Prolonged time to peak effect:  

o 10-15 minutes intravenously (Von Heimendahl & Cariou, 2009; Dugdale, 2010)

o 30-40 minutes intramuscularly (Von Heimendahl & Cariou, 2009; Dugdale, 2010) 

• Prolonged duration of action

• Non-antagonisable

• Hypotension via peripheral vasodilation.  Can be exacerbated in an animal that may already be dehydrated, susceptible to haemorrhage and/or experiencing positional hypotension ((Von Heimendahl & Cariou, 2009; Kushnir & Epstein, 2012; Claude & Meyer, 2016).  (See Caesarean sections: Part 1: Physiology of the pregnant patient). 

• Hypothermia from resetting of the thermoregulatory centre and peripheral vasodilation 

• May cause bradycardia (Kushnir & Epstein, 2012) 

• Neonatal liver has a limited capacity to metabolise phenothiazines (Von Heimendahl & Cariou, 2009).

However, if a degree of maternal sedation is necessary prior to C-section some authors suggest cautious administration at very low doses following a risk-benefit assessment (Moon et al, 2000; Moon-Massat & Erb, 2002; Murrell, 2007; Dugdale, 2010).


• Readily cross the placenta (Claude & Meyer, 2016; Murrell, 2016)

• Cause profound, dose related sedation

• Cause profound, short-lived, analgesia

• Initial peripheral vasoconstriction, with subsequent hypertension, a reduction in cardiac output (by up to 50%) and bradycardia. 

These effects can negatively affect both the dam and neonates.

Xylazine, an originally marketed alpha-2 agonist, was specifically identified as risk factor for increased puppy mortality following C-section (Murrell, 2007; Murrell, 2016).

Antagonism of alpha-2 agonists

“Reversal” of the sedative and unwanted side effects also antagonises the analgesic effects. 

Alternative pain relief should therefore be administered 

If it is determined that alpha-2 agonists are required e.g. for the genuinely difficult patient, then a low dose should be selected following a risk-benefit analysis, and the effects antagonised once the animal is anaesthetised (Claude & Meyer, 2016).


Benzodiazepines e.g. midazolam & diazepam, should be avoided or used very cautiously following a risk-benefit analysis.

• Rapid transfer across the placenta

• Readily absorbed by the foetus

• Immature neonatal liver does not possess the hepatic enzyme systems required for efficient metabolism (Von Heimendahl & Cariou, 2009). 

• In humans, maternal benzodiazepine administration has been associated with low infant Apgar scores, apnoea, cyanosis, sedation and reduced suckling (“floppy infant syndrome”) (Celleno et al, 1993; Luna et al, 2004).

• Neurological depression has been observed in puppies delivered following midazolam/ketamine anaesthesia (Moon-Massat & Erb, 2002).

Click here to download the Summary: Caesarean sections. Selection of premedication protocols.

Article by
Dr. Karen Heskin

Originally published: Wednesday, 9th June 2021
Last updated: Thursday, 10th June 2021


Celleno D et al (1993). Which induction drug for Caesarean section? A comparison of thiopental sodium, propofol and midazolam. J Clin Anaesth, 5: 284-288

Clarke K., Trim C. & Hall L.W. (eds) (2013). In: Veterinary Anaesthesia. 11th edition. Saunders Ltd

Claude A. & Meyer R.E. (2016). Chapter 26: Anaesthesia for Caesarean section and for the pregnant patient. In: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd edition. British Small Animal Veterinary Association, Gloucester, UK

Dugdale A. (2010). Veterinary Anaesthesia: Principles to Practice. Wiley-Blackwell, Chichester, UK.

Grimm K.A. (ed) (2015) In: Lumb & Jones Veterinary Anaesthesia and Analgesia. Wiley & Sons.

Kushnir Y. & Epstein A. (2012). Anaesthesia for the pregnant cat and dog. Israel J Vet Med, 67: 19-23

Luna SPL et al (2004). Effects of four anaesthetic protocols on the neurological and cardiorespiratory variables of puppies born by Caesarean section. Vet Rec, 154: 387-389

McElhatton PR (1994). The effects of benzodiazepine use during pregnancy and lactation. Repro Toxicol, 8: 461-475

Moon P.F. et al (2000). Perioperative risk factors for puppies delivered by caesarean section in the United States and Canada. JAVMA, 36: 359-368

Moon-Massat PF & Erb HN (2002). Perioperative factors associated with puppy vigour after delivery by Caesarean section. J Am Anim Hosp Assoc, 38: 90-96

Murrell J. (2007). Choice of premedicants in cats and dogs. In Practice, 29:100-106

Murrell, J.C. (2016). Chapter 13. Pre-anaesthetic medication and sedation, In: Duke-Novakovski T, de Vries M. & Seymour C. (eds) BSAVA Manual of Canine and Feline Anaesthesia & Analgesia. 3rd Edition. British Small Animal Veterinary Association. Gloucester, UK

Robertson S. (2016). Anaesthetic management for caesarean sections in dogs and cats. In Practice, 38: 327-339

Von Heimendahl A. & Cariou M. (2009). Normal parturition and management of dystocia in dogs and cats. In Practice, 31: 254-261

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Pain, what a Pain! How Locoregional Anaesthesia can Improve the Outcome and Welfare of Veterinary Patients (Part 1)

In this first article out of a series of two, Dan takes us through an introduction and practical tips for appropriate local anaesthesia delivery. Find out why these anaesthesia techniques, that are well recognised in human medicine, have seen an increase in popularity in veterinary medicine over the recent years

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Perspectives on Premeds – Opioids

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This second article aims to provide a refresher on opioids.

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Effects of Dexmedetomidine with Different Opioid Combinations in Dogs

Read the highlights of a recently published research paper that evaluates cardiorespiratory, sedative and antinociceptive effects of dexmedetomidine alone and in combination with morphine, methadone, meperidine, butorphanol, nalbuphine and tramadol. 

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Preoxygenation Study Highlights

This study evaluates the effectiveness of two methods of preoxygenation in healthy yet sedated dogs and the impact of these methods on time taken to reach a predetermined haemoglobin desaturation point (haemoglobin saturation (SpO2) of 90%) during an experimentally induced period of apnoea.

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Capnography – Not Just a Load of Hot Air

Capnography is the measurement of inhaled and exhaled carbon dioxide (CO2) concentration. The graphical illustration of CO2 within respired gases versus times is known as the capnogram.

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Perspectives on Premeds – Alpha-2 Agonists

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This first article aims to provide a refresher on α2 agonists.

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Alfaxan - now licensed for use in pet rabbits

Jurox Animal Health is delighted to announce that Alfaxan is now licensed for cats, dogs and pet rabbits. This is an exciting advance and could change the way rabbits are anaesthetised in the U.K.

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