animals

Review
Dead or Alive? A Review of Perinatal Factors That Determine
Canine Neonatal Viability
Oliwia Uchańska , Małgorzata Ochota * , Maria Eberhardt and Wojciech Niżański

Department of Reproduction and Clinic of Farm Animals, Faculty of Veterinary Medicine, Wroclaw University of
Environmental and Life Sciences, 50-366 Wroclaw, Poland; o.uchanska@gmail.com (O.U.);
maria.eberhardt@upwr.edu.pl (M.E.); wojciech.nizanski@upwr.edu.pl (W.N.)
* Correspondence: malgorzata.ochota@upwr.edu.pl

Simple Summary: The article summarizes the current knowledge on factors related to pregnancy,
parturition, and newborns that affect the health status of a puppy and determine its chances for
survival and development. The detailed information is provided in terms of breed predispositions,
objectives of pregnancy monitoring, potential sources of complications, and veterinary advances in
care and treatment of perinatal conditions. Successful pregnancy outcomes still pose challenges in
veterinary neonatology; thus, publications presenting the current state of knowledge in this field are
in demand.

Abstract: The perinatal period has a critical impact on viability of the newborns. The variety of
factors that can potentially affect the health of a litter during pregnancy, birth, and the first weeks of
life requires proper attention from both the breeder and the veterinarian. The health status of puppies
can be influenced by various maternal factors, including breed characteristics, anatomy, quality of
nutrition, delivery assistance, neonatal care, and environmental or infectious agents encountered
Citation: Uchańska, O.; Ochota, M.;
during pregnancy. Regular examinations and pregnancy monitoring are key tools for early detection
Eberhardt, M.; Niżański, W. Dead or
of signals that can indicate disorders even before clinical signs occur. Early detection significantly
Alive? A Review of Perinatal Factors
increases the chances of puppies’ survival and proper development. The purpose of the review was
That Determine Canine Neonatal
to summarize and discuss the complex interactions between all elements that, throughout pregnancy
Viability. Animals 2022, 12, 1402.
https://doi.org/10.3390/
and the first days of life, have a tangible impact on the subsequent fate of the offspring. Many of these
ani12111402 components continue to pose challenges in veterinary neonatology; thus, publications presenting the
current state of knowledge in this field are in demand.
Academic Editors: Daniel
Mota-Rojas, Julio Martínez-Burnes
Keywords: dog; pregnancy; parturition; puppy; neonatology
and Agustín Orihuela

Received: 1 May 2022

Accepted: 27 May 2022
Published: 30 May 2022 1. Introduction
Publisher’s Note: MDPI stays neutral The main goal for dog breeders and their veterinary associates is the successful rearing
with regard to jurisdictional claims in of puppies. High mortality rates can affect even litters that receive the best care.
published maps and institutional affil- Depending on the cause, it can range from 8 to 20% [1–5]. This paper summarizes the
iations. main findings regarding the maternal, pregnancy, and newborn-related components that
eventually would determine puppy survival. Analyzing maternal and pregnancy-related
factors emphasizes the need for tailored care for each pregnant female. This is particularly
true for pedigree bitches, which can be prone to obstetric complications due to the anatomy
Copyright: © 2022 by the authors. of their birth canal [6–8], as is observed with brachycephalic bitches [9,10]. The combination
Licensee MDPI, Basel, Switzerland.
of female age and body size also affects the potential number of puppies per litter [11,12].
This article is an open access article
This is an important risk factor, especially for females older than 6 years, for miniature and
distributed under the terms and
giant breed females with singleton pregnancies, and giant breed bitches carrying more than
conditions of the Creative Commons
11 fetuses [13,14]. These cases are exposed to primary and secondary uterine inertia, which,
Attribution (CC BY) license (https://
as the data in the literature indicate, would pose a direct threat to puppies’ lives [3]. The
creativecommons.org/licenses/by/
4.0/).
health status of the dam and the level of care are also of considerable importance.

Animals 2022, 12, 1402. https://doi.org/10.3390/ani12111402 https://www.mdpi.com/journal/animals

Animals 2022, 12, 1402 2 of 26

Pregnancy is a demanding state that can be significantly affected by the development

of any metabolic and hormonal disorders that, if diagnosed too late, can cause serious
health complications or even death of both the mother and the litter. Although not all
complications encountered by a pregnant or delivering bitch will be fatal, many of them
may significantly affect the health of the offspring in those first crucial days and weeks of
life. This paper aims to provide and discuss up-to-date knowledge concerning the most
important pre- and postnatal factors that may affect the health and survival of puppies
during the first weeks of life.

2. Maternal and Pregnancy-Related Factors

2.1. Anatomy and Breed Predispositions
There is no doubt that of all the factors that affect puppies’ health at birth, maternal
factors are the first to play the most important role right from the very beginning of
pregnancy. The health status and age of the bitch at the time of conception are most
important for the subsequent embryonic and fetal development. Moreover, a full clinical
examination should be performed, including a complete blood count and vaccination
status, and the general health status should be considered before deciding on breeding
a particular animal. During pregnancy, some hematological changes usually occur and
should be closely monitored, especially red cell and platelet counts. Gestational anemia
and thrombocytopenia are normal findings; however, if excessively low, these may affect
the course of pregnancy and lead to clotting problems during the caesarean section.
Undoubtedly, special attention should also be paid to the breed of the dam and the
sire breed. Breed identity determines typical anatomical structure and is closely related to
the predisposition to perinatal complications [6]. The percentage of these complications
increases with the prevalence of certain anatomical characteristics. Among these, the pelvic
structure and shape and the skull size are very important for the passage of the fetus
through the birth canal during delivery [10]. Serious problems in this regard, due to the
disproportionately large size of the fetal head in relation to the size of the birth canal, are
encountered in brachycephalic breeds. Bitches of these breeds have a predisposition to
perinatal complications almost 11 times higher than in other breeds [10]. This results in
an elective cesarean section becoming the norm as natural delivery poses a too high risk
for the litter. CT pelvimetry studies have shown that English bulldogs have a significantly
smaller pelvis and pelvic canal compared to non-brachycephalic dogs of the same weight.
Furthermore, the pelvic conformation is characterized by a significantly shorter pelvis
and pelvic canal and a significantly narrower caudal opening of the pelvis [9]. Problems
related to pelvic anatomy have also been reported in some medium-sized breeds, such
as Scottish terriers and Boston terriers [6,7]. X-ray measurements in bitches diagnosed
with birth complications due to fetal-pelvic disproportion showed a smaller pelvis and
a dorsal-ventral flattening of the pelvic canal. Whereas, in Boston terrier bitches, the
problem was also caused by a combination of the pelvic shape described above and the
relatively large head size of mature fetuses. Such characteristics significantly increase
predisposition to obstructive dystocia and secondary uterine inertia [6,7,15]. According to a
study conducted on a population of ~200,000 bitches registered with Swedish Kennel Club
(Stockholm, Sweden) between 1995 and 2002, Scottish terriers were the most susceptible
to dystocia resulting in emergency cesarean section [16]. The welfare of breeding dogs
has gained increased interest in recent years. Improved understanding that dystocia may
pose a greater risk in particular breeds of dogs should contribute to reducing the general
popularity of such breeds and help veterinarians and kennel clubs to better focus their
resources on strategies to limit breeds with high risk of dystocia [1,17].
In addition to the pelvic bone shape, the structure of the soft tissues in the birth
canal can also create a problem. It has been proven that abnormal vaginal anatomy can
affect fertility, as it prevents natural mating. The presence of adhesions, septations, or
double cervical orifices should be diagnosed before the bitch is intended for breeding [18].
Moreover, if detected, such females should be excluded from breeding, as these defects
Animals 2022, 12, 1402 3 of 26

might be transmitted to the next generation [19]. A study comparing the fertility of bitches
undergoing surgical vaginal correction and those without surgery showed that although
there was a relatively non-significant effect on reproductive performance, pregnancy rates
were substantially lower in the group of bitches with severe abnormalities. Furthermore,
the same group of bitches showed a markedly greater predisposition to dystocia and thus
cesarean section than the group of bitches with mild abnormalities [8].

2.2. Inbreeding
When analyzing the causes that could affect the litter size, inbreeding should also be
considered. According to research, a high inbreeding rate can result in impaired fertility
and therefore a reduction in the number of pups in the litters that are born [20]. In pedigree
dogs, breeding decisions on mating closely related individuals are motivated by the need to
obtain the desired phenotype or behavioral traits, leading to genetic bottlenecks. Targeted
selection in pedigree dogs for traits of morphology and performance has greatly decreased
fertility rates, increased reproductive problems, and significantly contributed to dystocia
due to anatomical disproportions in some breeds [10]. The most notable among these
are brachycephalic breeds, in which reproduction without assisted mating and a planned
caesarean section is today almost not feasible [21]. Focusing on breeding for desired
appearance alone raises a lot of public concern today, which hopefully will lead to better
awareness and more responsible dog breeding in future.
The availability of genetic tests dedicated to particular breeds is also worth mentioning.
Today, the problem of selecting pairs of animals for breeding rests mainly on the responsible
approach of the owner, and any poorly considered actions can lead to the perpetuation of
traits detrimental to the health of dogs and the narrowing of their genetic pool [22]. The
number of breed-specific conditions increased at more than 100% between year 2013 and
2020 [23]. The range of dedicated tests for their identification is also growing steadily [23].
Among the 10 breeds for which test availability is the greatest, are Labrador Retriever,
Beagle, Australian Shepherd, German Shepherd, Standard and Miniature Poodle, Golden
Retriever, Collie, Pembroke Welsh Corgi, and Dachshund [23]. Detailed information on the
range of genetic tests for detecting inherited diseases can be accessed online at: The WSAVA-
PennGen DNA Testing Database, which is part of “A project of the WSAVA Hereditary
Disease Committee” [24].

2.3. The Impact of Litter Size

When considering the influence of maternal factors, one cannot forget to mention their
effect on the litter size. The litter size directly affects the safety of puppies during birth and
depends on the mother’s age, breed, and the breeding method [11,12]. The larger the breed,
the more pups a litter would potentially contain (up to 11–12 pups), whereas in small and
miniature breeds on average, up to 3–5 pups are more common [11,13,14].
Large females have a larger uterine capacity and are able to accommodate more fetuses;
hence, their litters are naturally more numerous than those of smaller females. In larger
breeds, the small size of the litter is especially important because a small number of pups
may not give enough strong signals to induce labor [25]. Furthermore, multiple litters of 12
or more pups can cause primary uterine inertia by overstretching the myometrium, leading
to weak uterine contractions, or secondary uterine inertia, where the uterine myometrium
is exhausted by prolonged labor [6,11,13].
Regardless of the litter size, the last pup is at the highest risk of stillbirth [6]. Some
authors pointed out that high perinatal mortality most often affected the first pregnancy of
a given dam; in addition, the risk of early neonatal mortality nearly doubled in litters with
a concurrent incidence of stillborn pups during birth [13].
Animals 2022, 12, 1402 4 of 26

Large litters can also be associated with risks to maternal health. Among other things,
it can be one of the factors contributing to the bitch’s disease during pregnancy and it
can increase the risk of dystocia. Gestational toxemia, for example, occurs most often
secondarily to a negative energy balance associated with inadequate nutrition and largely
with the presence of a large litter of puppies [26,27].
The importance of maternal age played a role in very young (1 year and under) and
older (6 years and older) bitches, that tend to have fewer pups (one or two) than bitches
aged 2 to 5 years [13,14]. It is worth noting here that primiparous bitches older than
6 years are predisposed to single-puppy pregnancies, uterine disorders, and prolonged
labor [3,13]. Hence, such factors would significantly increase the risk of dystocia, and it is
highly inadvisable to breed bitches over 6 years of age [13].
The mating method can also be a limiting factor in terms of the number of offspring.
The most commonly used method is natural mating or artificial insemination (AI). AI
can be intravaginal, intracervical, or surgical, using fresh, chilled, or frozen semen [28,29].
The highest efficiency in obtaining numerous litters was reported through natural mating
rather than with the artificial insemination method [11]. However, natural mating has
become less and less popular among dog breeders, mainly due to the need to travel long
distances for a chosen male. This makes breeders much more eager to choose the artificial
insemination methods and shipped semen [29]. The use of the artificial insemination
method also provides highly satisfactory results in terms of litter size, especially when
using fresh semen rather than chilled or frozen-thawed [12,30].

2.4. Maternal Health Condition

The course of a pregnancy fundamentally determines the health of a newborn during
its first weeks of life. The number of factors that may affect the mother’s condition during
this period is innumerable. They can be divided into those related to the bitch, such as
current health state or ability to maintain hormonal balance, and those that are external:
mainly the diet and the quality of pregnancy monitoring. During the pregnancy, several
disease entities can also develop such as gestational toxemia, diabetes, and eclampsia. The
pregnancy can also be affected by corpus luteum insufficiency, which is a serious disorder
at the ovarian level [26,31]. Awareness of the potential risks to the mother and the level
of care provided if complications arise are vital and can significantly impact the future of
any litter.

2.4.1. Pregnancy Toxemia and Diabetes Mellitus

Canine pregnancy toxemia can pose a serious life threat to both the bitch and her
fetuses. The disorder, which is mainly seen in late pregnancy, is characterized by hypo-
glycemia, ketosis, ketonuria, and liver lipidosis, presenting with weakness, which can later
progress to seizures, collapse, and even death [32]. Bitches with multiple litters are more
at risk of developing toxemia, especially if they show signs of anorexia during the last
two weeks of pregnancy [18]. The diagnosis is based on clinical signs and the presence of
hypoglycemia combined with high concentrations of ketone bodies in blood and urine, and
treatment involves glucose supplementation [15,32,33].
Symptoms similar to gestational toxemia may also be observed during gestational
diabetes, which is often developed without the typical clinical signs evident. A syndrome
resembling gestational diabetes in humans may occur in older female dogs during preg-
nancy. Insulin resistance is a normal feature of pregnancy [33]. Two factors promoting
insulin resistance, progesterone and growth hormone, are present in similar concentrations
in pregnant and non-pregnant bitches in diestrus [34]. Progesterone stimulates the secretion
of growth hormones from the canine mammary gland, and both hormones cause insulin
resistance and carbohydrate intolerance in the dog [35]. However, pregnant bitches are
more insulin-resistant than non-pregnant diestrus bitches [36]. The diagnosis of gestational
diabetes mellitus (GDM) is based on history and clinical findings and is confirmed by
documenting the persistent hyperglycemia with glucosuria. In humans, GDM is associated
Animals 2022, 12, 1402 5 of 26

with excessive fetal growth (macrosomia), which contributes to dystocia and birth trauma,
and, as a result, increased maternal, fetal, and neonatal morbidity and mortality [37,38]. In
humans, the prevalence of congenital malformations is higher than in the general popula-
tion if GDM occurs early in pregnancy, but not in mid-pregnancy or later [39]. In bitches
diagnosed with gestational diabetes mellitus, fetal viability should be assessed regularly
with ultrasound; knowing whether the pups are large enough to be at risk of dystocia or
are no longer alive would guide treatment decisions, such as the schedule of the cesarean
section. Such puppies would be at increased risk of premature delivery if CS was decided
too early, while if delayed too long, it would lead to fatal distress and metabolic disorders.
Published reports of managing canine GDM are rare [35,36,40]. Similar to humans, in case
of GDM neonatal hypoglycemia, hyperbilirubinemia, hypocalcemia, and poor suckling can
occur more frequently in puppies, and proper management involves intensive fluid and
insulin therapy to correct water, electrolyte, acid-base, and glucose derangements [33,40].

2.4.2. Hypoluteoidism
Hypoluteoidism is described as insufficient production and secretion of progesterone
by the corpus luteum [41]. Necessary to maintain pregnancy, proper corpus luteum
function and progesterone production, if defective, can determine the fate of any pregnancy
at its very early stage. A serum progesterone level of at least 2 ng/mL is considered
by many authors to be the key to maintaining a canine pregnancy [34,42]. A decrease
in progesterone concentration below 2 ng/mL in a pregnant bitch has been shown to
lead to abortion [34,42]. Interestingly, some authors reported that miscarriage can occur
even when the progesterone level drops below 10 ng/mL [43]. Since serum progesterone
measurements can be performed using a variety of methods and devices on the market,
with RIA being considered the reference assay, the exact progesterone values may vary
between published studies and reports [44]. In all cases, the interpretation of the results
should be approached with caution and the device and method used should always be
considered when analyzing the progesterone concentration.
Distinguishing between corpus luteum insufficiency as the primary cause of fetal
death, rather than its consequence, is certainly worth attention, especially in bitches who
lose litters in the second half of pregnancy despite the exclusion of other causes. The
reasons and pathogenesis of corpus luteum insufficiency, despite many studies, are still
incompletely investigated and diagnosis often poses a problem because many factors, such
as maternal health status, fetal death, infectious agents, trauma, or poor nutrition, may
contribute to the primary decrease in progesterone level [34,45,46]. Some studies confirmed
the association of corpus luteum insufficiency with the presence of IgE antibodies against
endogenous progesterone in bitches [47]. These authors suggested a genetic link to the
occurrence of hypoluteoidism in specific breeds, such as German Shepherds.
The diagnosis of primary corpus luteum insufficiency as a cause of pregnancy loss
is complex. It requires confirmation of a gradual decrease in progesterone levels while
assessing fetal viability. The possibility that the decrease in serum progesterone levels
occurred due to fetal distress or abortion must be excluded. The function of the corpus
luteum can be influenced by many endo- and exogenous factors that control its lifespan, and
among the most important substances with luteolytic effects are PGF2a and antigestagens
such as aglepristone [46,48].
If the diagnosis is confirmed, exogenous progestin supplementation therapy is rec-
ommended, of which medroxyprogesterone acetate (MPA), alternogest, or progesterone
in oil are the most commonly used in dogs [34,49]. The administration of progestins in
pregnant bitches may be associated with side effects such as the development of pyometra,
septicemia, or placentitis, and the risk of prolonged pregnancy-causing dystocia [34,42,50].
Furthermore, progestogens, which have androgenic effects, may lead to masculinization of
female fetuses [42].
Animals 2022, 12, 1402 6 of 26

Recently, the first documented case of mammary gland fibroadenoma in dogs, so far
reported only in cats, has also been described. An Istrian Shorthaired Hound bitch was
diagnosed with primary corpus luteum insufficiency in three consecutive pregnancies [51].
Based on the diagnosis established during the first pregnancy, in the second one with re-
peated suspicion of corpus luteum insufficiency, the bitch was treated with 1.65 mg/kg of
progesterone in oil intramuscularly (PROGEST-E® , Fort Dodge Animal Health S.p.A., Bologna,
Italy) daily, from day 19 to day 22, and every 48 h from day 23 to day 58. During the third
pregnancy, based on previous experience, the bitch also received 0.075 mg/kg alternogest
(Regumate® , Intervet Italia S.r.l., Peschiera Borromeo, MI, Italy) from day 8 and then every
24 h until day 52 of pregnancy. The dose was reduced to 0.058 mg/kg PO from day 53 to
day 57 [51]. Both times, an increase in the size of the mammary glands was observed. One
of the pregnancies required a cesarean section due to fetal macrosomia. Whereas, females
born in the other pregnancy, according to the owner’s report, showed no signs of estrus cycle
during the first 3 years of life; moreover, in one female, clitoral hypertrophy and a blindly
ending vagina were diagnosed. Such abnormalities may be related to progestin treatment
in the embryogenesis stage, as they affect the development of the genital tract. If progestins
are used as a supplemental treatment for hypoluteoidism, administration should not begin
before days 30–35 to avoid genital abnormalities [49,52]. Since hypoluteoidism is an ovarian
dysfunction and its treatment with progestins might lead to severe unwarranted effects, it is
recommended to exclude affected bitches from breeding.

2.4.3. Hypothyroidism
An equally interesting topic is the relation between pregnancy and hypothyroidism.
In general, hypothyroidism is a common endocrine disease in dogs. Many previous studies
have demonstrated a heritable tendency in dogs of certain breeds, such as Toy Fox Terriers,
Giant Schnauzers, Boxers, or Scottish Deerhounds [53]. Bitches with untreated hypothy-
roidism often exhibit a significant reduction in fertility that prevents natural pregnancy, as
well as variable interestrus intervals, abortions, and stillbirths [54]. Studies have shown
that they are also at risk of developing dystocia as a result of a prolonged duration of labor
contractions and a decrease in their intensity. Puppies have been reported to have a higher
incidence of low birth weight, low viability, and overall increased litter mortality [54]. The
situation changed when levothyroxine supplementation was started, which was shown
to reverse the negative effect of hormone deprivation on neonates’ birth weight and high
mortality [55]. The question of changes that occur in thyroid hormone concentrations
during the course of pregnancy in bitches certainly requires further study. Some data
indicated insignificant fluctuations that do not require adaptive hormonal supplementa-
tion during pregnancy [56,57]. In contrast, others suggested that significant changes may
occur, especially during the second half of pregnancy, when the rate of fetal development
increases, and therefore the rate of maternal metabolism should follow to meet the energy
demands [42,58]. The same is true in human pregnancy, where adequate supplementation
during pregnancy is necessary for its maintenance and must be gradually increased, as well
as the fetal development and metabolic rates [59]. In bitches experiencing miscarriage, a
significant decrease in thyroid hormones and a correlating decrease in progesterone levels
were observed even one week before the first clinical symptoms [42]. The problem of
levothyroxine supplementation recommendations and the need to increase the dose with
the progression of pregnancy certainly require further research and attention; this is still
a matter of debate according to different study results [56–58], because decisions made
during treatment can have a significant impact on the outcome of the bitch’s pregnancy
and therefore the health status of the whole litter.
Animals 2022, 12, 1402 7 of 26

2.4.4. Maternal Microbiota and Its Effect on Puppy Survival

The development of the newborn microbiota is a gradual process, influenced by many
factors. The environment, the health status of the mother and, above all, the intake of
colostrum, are essential in the first hours of life [60].
The colostrum in mammals is the first food of crucial importance for the health of
the offspring in the early neonatal period. In canine species, only 5–10% of antibodies can
cross the placenta, so newborns are almost completely immune-deficient [61]. The timing
and amount of colostrum intake immediately after birth are important for their survival
and future health. The intestinal barrier is only permeable to IgG from the gastrointestinal
tract during the first 12–16 h of life, so it is important to feed newborns with colostrum as
soon as possible shortly after birth [61]. Although the exact mechanisms that determine the
formation of the colostrum microbiota are not fully understood, studies seem to support
the enteromammary hypothesis that the colostrum microbiota is shaped by gut bacteria
present in the dam [61].
The relationship between colostrum microflora and intestinal microflora of neonates
is confirmed by studies in which the composition of meconium collected from neonates
was found to be similar to that of colostrum collected from dams [61]. Adequate microflora
composition determines colonization of neonatal intestines, and this directly translates
into their chances of survival, adaptation to the ectopic environment, and development of
health status [60].
Studies on supplementation of pregnant bitches with prebiotics containing, among
others, E. faecium and L. acidophilus proved their influence on producing better quality
colostrum, which improved the immunity of puppies. Furthermore, the maternal micro-
biota, positively altered by supplementation, was transferred to newborns, making the
offspring more resistant to gastroenteritis [62].
The type of parturition can also be a factor that affects the composition of the microflora
of the colostrum [61]. Whether it is vaginal delivery, emergency cesarean section, or elective
cesarean section, the colostrum samples contained different microorganisms. The colostrum
of the bitches with vaginal delivery and elective cesarean section was characterized by a
similar composition, unlike the colostrum collected from the bitches undergoing emergency
cesarean section [61]. It should be noted that the differences may result from the fact that
bitches in the latter group usually experience higher levels of stress as well as some degree
of exhaustion.
Recent findings concerning the placental microbiome in healthy pregnant dams also
indicate the possibility of early intrauterine bacterial colonization of the fetuses [63]. The
bacterial composition of the neonatal meconium resembled that of the maternal vagina in
the pups born by vaginal delivery. The ones born via CS had microflora similar to the oral
and vaginal microbiota of the mother [63].
It should also be noted that the presence of the gut microbiota can contribute to better
weight gain in puppies, which is essential for their future development and health status in
adulthood [61,63]. Puppies in which bacteria could not be cultured from meconium had a
slower growth rate compared to puppies with some bacteria present in their meconium [63].
It is also extremely important for the health of the offspring to maintain the balanced
composition of their intestinal microbiota. The underdeveloped immune system can
be easily affected by the gut microflora imbalance, which may lead to the growth and
multiplication of undesirable pathogens such as Proteobacteria and Pasteurellaceae, and
may progress towards serious disorders, mainly Fading Puppy Syndrome (FPS), which
can often cause fatal results [64]. The evaluation and culture of the intestinal microflora
composition and the fecal samples of puppies can therefore become a helpful tool in the
diagnosis of neonatal problems.
Animals 2022, 12, 1402 8 of 26

2.4.5. Challenges in Pregnancy Nutrition

Proper nutrition has an important impact on the health of the mother and her offspring
during pregnancy and the subsequent lactation. The connection between reproduction and
nutrition is undeniable and awareness of key aspects of bitch nutrition during pregnancy,
perinatal period, and lactation is a prerequisite for success in healthy breeding. Facing
differences in reproductive animals’ nutritional needs, Association of American Feed
Control Officials (AAFCO) has published separate nutrient profiles with different feeding
trial protocols for maintenance, growth, and gestation-lactation periods [65]. Energy
requirements gradually increase in the bitches from day 40 of gestation, on average by
nearly 10% for each additional week, to about 1.25–1.5 times those of normal maintenance
requirements. The amount of food provided should be properly recalculated to prevent
excessive weight gain [66]. Many owners believe that large amounts of energy are required
from the very beginning of the pregnancy. They start to overfeed pregnant bitches, which
can result in increased fat deposition [66]. Unfortunately, obesity is one of the factors that
strongly predispose to dystocia, which most likely decreases uterine contractions during
labor due to excessive fat deposition in muscle tissue [6,67]. It is also worth noting the
practice of dividing the daily dose into several smaller meals. It prevents the stomach from
overloading with too much food, especially in late pregnancy, when a large part of the
abdominal cavity is filled with the gravid uterus [66].
Just as important as quantity is the quality and type of food provided. A study con-
ducted among a group of breeders in Canada about their feeding practices has shown that
a substantial percentage of breeders were unable to determine whether the commercial
food they were feeding met the AAFCO recommended standards. In addition, nearly
16.9% of breeders participating in that survey, who fed commercial diets, reported offering
diets to pregnant and lactating bitches that are not intended for the gestation-lactation
period. Moreover, almost 9% of breeders weaned puppies onto a diet not designed for
the growing puppies [68]. An alternative to commercial diets available on the market is
the bones and raw food diet (BARF), prepared by owners or breeders at home, sometimes
with specific additives [69]. Its nutritional value for pregnant and lactating bitches and
growing pups is difficult to assess and very likely BARF diet would not meet the demands
of breeding animals [68,69]. This type of diet may also increase the risk of infection with sev-
eral pathogens and parasites responsible for reproductive disorders, including Salmonella
spp., Campylobacter spp., Neorickettsia spp., Shiga toxin and hemorrhagic Escherichia coli,
Toxoplasma sp., and Neospora sp. [68].
When selecting foods for pregnant and lactating bitches, attention should also be paid
to the content of the particular ingredients and the use of various additives (e.g., mineral
supplements, dairy products); breed-related demands should also be considered here,
especially regarding calcium content [66,70]. Some breeders believe that calcium addition
can ensure adequate lactation and healthy development of puppies [66]. However, a lack
of consideration in calcium supplementation may cause more harm than benefit. Calcium
homeostasis is tightly regulated by parathyroid hormone (PTH) and calcitonin [71]. During
pregnancy, a physiologic decrease in calcium serum levels leads to a series of reactions
designed to elevate it again. Under the action of parathyroid hormone (PTH), an increased
release of calcium from bones and enhanced absorption from the gastrointestinal tract
takes place [70,71]. When a bitch receives extra calcium with food, the serum calcium
concentration remains sufficiently high, and there is no need to activate the mechanisms of
calcium release from bones and increase the intestinal absorption, which downregulates
the PTH activity. Then, with the onset of lactation, a bitch cannot precisely respond to the
high calcium demand and the risk of developing eclampsia increases [66]. Eclampsia most
often occurs in small and miniature breeds, usually after birth, but sometimes might also
be observed during pregnancy [15]. Clinical signs are initially nonspecific, but can progress
to muscle tremors, ataxia, elevated rectal temperature above 39.7 ◦ C, tetany, and in severe
cases, even death [70]. Treatment is based primarily on intravenous calcium administration.
Animals 2022, 12, 1402 9 of 26

If possible, the litter should be weaned permanently and hand-reared to prevent the risk of
hypocalcemia relapse.
Another nutrient that has also attracted interest is folic acid, recommended for preg-
nant women. Experiments conducted on mice as experimental animal models also demon-
strated that folic acid is necessary for normal embryonic-fetal development [72,73]. Some
studies have shown its important role in the prevention of cleft lip and/or palate in
brachycephalic puppies [74–76]. However, no similar relationship was proven in a study
conducted on bitches of breeds considered as non-predisposed (Labrador, Golden Retriever,
and Labrador/Golden crosses) to the cleft palate problem [77]. If considering supplemen-
tation in dogs, studies suggest one should start folic acid when a bitch is intended for
breeding/enters the estrus phase, since the medullary tube closes during the first part of
gestation to reduce the risk of developing cleft lip or palate [66].
The crucial importance of a proper diet for the health of the pregnant bitch and her
offspring remains undisputed. In addition to portioning daily food intake and administer-
ing it in appropriate amounts to avoid excessive weight gain, the trend of administering
certain supplements deserves attention, especially calcium and folic acid supplementation.
A rational approach to the use of nutritional supplements and the application of sound
feeding practices are key aspects in providing adequate care to the pregnant bitch.

2.4.6. Pregnancy Monitoring

In routine care of pregnant females, periodic examinations are recommended to evalu-
ate the pregnancy development. US pregnancy scanning, if performed by an experienced
person, would allow for early detection of abnormalities. Defective trophoblast invasion
is believed to be the basis for abnormal blood flow in the uterine artery, which in turn
leads to uteroplacental insufficiency [78]. Alarming changes include reduced diameter and
abnormalities in the contour of the gestational vesicle, lack of viability, increased placental
thickness, increased fluid echogenicity, and increases in RI (resistivity index) and PI (pul-
satility index) of uteroplacental arteries of conceptuses [78]. The appearance of changes
correlates with the onset of embryo resorption around weeks 2 and 4 of gestation [78]. The
umbilical artery and the fetal renal artery were also useful in evaluating the quality of
fetal-maternal flow; its abnormal parameters suggest gestational pathology [79]. Differ-
ences were also reported in the blood flow of the uterine and umbilical arteries in small,
medium, and large breeds of dogs during the second half of pregnancy. Conversely, during
this same period, FHR did not vary between small, medium, and large breeds [80]. This
indicates that physiological variations should also be considered when a gestational ultra-
sound is interpreted in different breeds of dogs. Doppler ultrasound also has a prognostic
value in assessing the effect of the morphology of the ductus venosus (DV) waveform on
canine neonatal mortality. One study showed that litters in which three-phase waves of DV
(tDVw) were recorded had a higher (almost 21 times more) chance of neonatal mortality
(one or more dead pups per litter) than those with only two-phase waves (dDVw) [81]. DV
postnatal patency could also lead to a congenital portosystemic shunt (CPSS). Non-invasive
color flow mapping (CFM), which is used routinely to diagnose CPSS in adult dogs, has
been shown to be equally useful to confirm or exclude DV closure within the first ten
days after delivery in canine neonates. This might become useful for early screening tests
evaluating the DV patency, especially in puppies of breeds predisposed to congenital por-
tosystemic shunts [82]. Changes observed during ultrasound examination may indicate the
development of pregnancy pathology long before the first visible symptoms appear [83].
In addition to ultrasonography, electrocardiography can sometimes be useful to detect
pathologies in specific electrocardiographic parameters, including QRS waveforms, mater-
nal heart rate (MHR), or fetal heart rate (FHR) [84]. The correct MHR should be around
70–120 bpm, while the fetal heart rate is between 180 and 220 bpm [85]. Any factor causing
fetal distress is most often manifested by fetal bradycardia and, therefore, changes in FHR.
A more complete picture of the disorder can be obtained by analyzing the FHR/MHR ratio,
which more accurately reflects fetal health in relation to maternal health than single FHR
Animals 2022, 12, 1402 10 of 26

values [85]. This is especially the case when combined with Doppler examination, which
enables one to visualize and compare the blood flow of the uteroplacental and umbilical
arteries in normal and abnormal conceptus [78]. Accurate understanding of the changes
that occur can contribute to early diagnosis for identification and, if possible, exclusion of
the problem to ensure the safety of the developing offspring.

3. Type of Delivery, Perinatal Complications, and Proper Management of the Bitch and
Her Offspring
3.1. Normal Parturition
The pregnancy in the bitch is expected to last between 57 and 72 days from the day of
mating [40,86]. Estimating the exact date of parturition in dogs is sometimes difficult. The
timing of ovulation is usually delayed in relation to both the LH surge and the liberation of
the immature ovum, which needs to mature further to be competent for fertilization in the
oviduct [87]. It is also necessary to consider the 24–48 h period in which the ovum can be
fertilized and the survival of the sperm in the reproductive tract, depending on the date of
mating or the type of insemination.
Serum P4 concentration is considered an essential parameter for the detection of the
LH peak, ovulation, and parturition date. Serum P4 concentration begins to increase before
the onset of the luteal phase, and the first day when P4 is >1.5 ng/mL is considered to
indicate the peak of LH [88]. On the day of ovulation, which occurs almost 48–60 h after the
peak of LH, the length of pregnancy is reported to be 63 ± 1 days (62–64 days) [40,88]. The
accuracy of parturition timing using prebreeding P4 concentration is described to be 67,
90, and 100% within 65 ± 1, ±2, and ±3 days, respectively [88]. Instead, vaginal cytology
for continuous monitoring of the reproductive cycle could be helpful in determining the
appropriate time to start serum P4 monitoring [86]. Vaginal cytology can also be used to
determine the first day of diestrus (D1), after which the pregnancy should last 57 ± 3 days
(54–60 days) [86]. The determination of D1 does not present difficulties because the image
in this phase of the cycle clearly differs from that in estrus by the decrease in the percentage
of cornified cells from 80–100% to at least 20%, and the appearance of parabasal cells and
neutrophils. These changes occur in less than 24–48 h [86].
A normal parturition in a dam is divided into three phases. In phase one, the pro-
gesterone block is lifted with the onset of uterine contractions and cervical dilation. The
duration varies between 6 and 24 h, possibly up to 36 in a primiparous or very nervous
bitch [40]. During the second phase of labor, uterine contractions are combined with abdom-
inal wall contractions, and the fetuses are expelled sequentially from the uterus. Although
there may be a longer interval between the first and subsequent pups, births usually occur
every 15 to 120 min, depending on the size and breed of the mother and the number of
puppies. The third phase involves placental expulsion and occurs immediately or within
15 min after the birth of each pup [40]. However, several placentas may be delivered at
once [89].

3.2. First Aid Delivery

Labor, for a variety of reasons, does not always proceed as expected and veterinary
assistance may be required when complications occur. A fast and accurate diagnosis of
dystocia is essential to increase the chances of survival of a newborn. The most impor-
tant predisposing factors to dystocia are those previously discussed, including maternal
age, size, breed, and the number of puppies [6]. Difficult labor can be approached with
conservative methods or surgical intervention. Conservative methods involve the use of
pharmacological substances and/or manual attempts to correct the fetal position in the
birth canal [5]. When trying to pharmacologically resolve difficult labor, oxytocin is admin-
istered most frequently [2]. Calcium gluconate and glucose are also recommended [89]. If
there is no response to drug therapy or obstetric maneuvers aimed at correcting dystocia,
and fetuses are confirmed to be alive, the dam should immediately be submitted for an
emergency cesarean section [5]. When considering the potential impact of the cesarean
Animals 2022, 12, 1402 11 of 26

section on the health of puppies, two key things should be remembered. One is related to
whether the cesarean section is performed as an emergency or a scheduled procedure, and
the other is the type of anesthetic protocol used during the intervention.

3.3. Emergency Cesarean Section

The emergency cesarean section is a procedure associated with a high risk to the
life of both the bitch and the puppies. Mortality rates can be as high as 20% of puppies
and 1% of bitches, especially in small and predisposed breeds, including predominantly
brachycephalic breeds like French Bulldog, Boston Terrier, Chihuahua, or Pugs [1–3].
The most common maternal causes include difficult fetal passage (narrow birth canal,
presence of undetected earlier congenital vaginal defects), disturbed labor (inertia, spasms),
prolonged pregnancy, uterine disturbances (torsion, malformations), and poor psychogenic
status (restlessness, abnormal or aggressive behavior) [1,3]. Fetal factors include puppy size,
especially oversized ones, fetal malpresentation, and the total number of the puppies [3].
Single pup pregnancies or abnormally high numbers of pups should always be treated
with special care because they are serious predisposing factors to delivery complications.
The longer it takes to deliver a puppy and the later the surgery is started, the less
chance of survival a puppy has. Severe fetal distress translates into heart rate per minute;
a drop below 180 bpm is an immediate indication for the surgical intervention, whereas
below 120 is a very poor prognosis for the puppy’s survival [21,90]. The published data
directly indicate that puppies born via emergency CS are more than 7.3 times less likely to
survive than those born via elective CS [21,91]. The most common cause of the pup death
is hypoxia due to prolonged labor and placental separation, often associated with large
numbers of fetuses, malpresentation, and wedging in the birth tract [3,92].

3.4. Planned Cesarean Section

One of the ways to prevent puppy loss due to dystocia is to schedule a cesarean
section. Specific indications for an elective CS are breed predisposition, maternal age, and
litter size. Females with previous birth complications and those of high breeding value
should also be considered. It has been proven that in some situations, scheduling a cesarean
section is the safest method of pregnancy termination both for the dam and her litter [91].
However, performing a cesarean section without clear indications at the owner’s own
request is the subject of much controversy and is considered unethical by some members
of the veterinary community. In the case of scheduled operation and for the safe surgical
outcome, the appropriate anesthetic protocol should be used, which considers both the
dam and the fetuses in the uterus.
In each of the types of delivery, the puppy viability assessment should be performed
and adequate treatment instituted if abnormalities are detected [5,93]. Timing is very
important for puppy survival, further development, and overall health status.

3.5. Neonatal Assessment

Neonatal viability can be evaluated using a modified APGAR score proposed by
Veronesi [94]. Five parameters are assessed, including mucus color, heart rate, reflex
irritability, motility, and vocalization. Points (0–2) are given for every parameter depending
on the condition of the newborn [94]. A heart rate above 220 bpm (beats per minute)
gets 2 points, between 220 and 180 gets 1 point, and below 180 gets 0 points. Respiratory
effort is assessed when the newborn is crying (>15 respiratory rate (rr)), moderately crying
(between 6 and 15 rr). Reflex irritability can be vigorous, a grimace alone can be visible,
or there may be no response. When assessing motility, it is possible to observe active
motion, some reflections, or flaccid movements. The last parameter, mucus color, can be
assessed as dark pink, pale, or cyanotic. The total amount determines the final APGAR
score, which identifies the degree of a newborn’s distress: 7 to 10 points mean no distress; 4
to 6, moderate distress; and 0 to 3, severe distress.
Animals 2022, 12, 1402 12 of 26

For brachycephalic breeds born by cesarean section, an exclusive scale has been
designed for the evaluation of brachycephalic newborns [95]. The scale was specially
modified after the Veronesi et al. scoring system and adapted to their characteristics due to
the lower degree of vitality after birth often observed in newborns of these breeds. A heart
rate above 180 bpm gets 2 points, between 120 and 180 gets 1 point, and below 120 gets 0
points [95]. Other parameters including respiratory effort, reflex irritability, motility and
mucus color are scored the same as in the APGAR scale proposed by Veronesi et al. [94].
Neonatal viability reflexes (NVR) can also be assessed. The purpose of this scale is
to evaluate a newborn’s postnatal depression based on active searching for the mammary
gland and the strength of the sucking, measured as weak, moderate, or normal [5].
These reflexes are essential in the early postnatal period to ensure newborn feeding
and survival. The suckling reflex can be assessed by inserting the gloved tip of the smallest
digit into the mouth of the neonate and checking the suckling force; it can be described
as strong (5 suckles/min), weak (>3 suckles/min) or absent. The rooting reflex can be
assessed by approaching the nose of the neonate with the forefinger and thumb shaped
into a circle and checking whether the neonate inserts its nose into this circle; immediate,
slow or absent muzzle fitting inside the circle can be observed. The righting reflex of the
neonate can be evaluated by placing it on its back on a soft surface and verifying whether
it is able to return to the sternal recumbence. Those reflexes are also scored from 0 to 2
points, and the interpretation is as follows: 0–2 points: weak viability; 3–4 points: moderate
viability; 5–6 means normal viability. Weak reflexes are often the primary sign of hypoxia
in puppies [5].
The better the viability of the newborn, the higher score it receives on each scale
mentioned above, and therefore the prognosis of its short-term survival would be better.
The transient decline in vital functions immediately after birth is often observed even
in eutocic pups [5]. Healthy newborns quickly regain their vitality; however, due to the
special vulnerability in the first few hours of life, each should receive special attention and
care. The critical and weak puppies (0–6 on the APGAR score) need even more attention
and care, as they are much more likely to have a fatal outcome within the first 2 h of life [5].
To increase the chances for survival of weak newborns, prompt and efficient resuscita-
tion is crucial. The protocol proposed by Traas et al. adopted the following sequence of
actions according to their importance: warmth, airway, breathing, circulation, and drug
administration [96]. In each case, the treatment should consist of clearing airways, drying of
a puppy, respiratory stimulation (cardiopulmonary resuscitation), oxygenation, ventilation
by a mask or endotracheal tube and, when necessary, fluid administration [5,96]. Intra-
venous administration of drugs such as doxapram, aminophylline, or epinephrine could
also be considered [96]. Naloxone can be given to reverse the anesthetic effect of opioids ad-
ministered to the dam prior to the cesarean section. In distressed newborns at risk of sepsis
due to hypoxia-induced bacterial translocation, the administration of safe antibiotics (these
include cephalosporins, penicillins, clavulanic acid, macrolides, trimethoprim-sulfonamide,
and amikacin) should be considered [18,96].
Blood glucose measurements are also helpful in assessing the risk in frail puppies.
Hypoglycemia (<40 mg/dL) within the first 8 h of life was associated with high mortality
in newborns during the first 24 h of life. At 24 h of life, the level of 92 mg/dL or below was
associated with a higher risk of mortality during the entire neonatal period (1–21 days) [4].
A second useful parameter for predicting neonatal mortality within the first 48 h of
life is the lactate level. Its concentration in the umbilical cord blood reflects the presence of
acidosis in a neonate, with high levels noted in distressed pups and low levels in healthy,
vigorous ones [97]. Both parameters combined with the neonatal APGAR score can be a
useful tool for the early identification of weak newborns that require special care, thus
reducing neonatal mortality.
Animals 2022, 12, 1402 13 of 26

Awareness must also be given to the fact that each evaluation should always be
objectively performed by experienced practitioners. Low scores do not always determine
a negative outcome for a puppy; however, high neonatal mortality is more frequently
correlated with it [90]. When performing a viability evaluation, each newborn should also
be checked for the presence of birth defects such as cleft lip/palate, presence of a hernia, or
atresia ani.

3.6. Postoperative Pain Management

An important aspect that should not be overlooked is proper pain management for
the dam after a cesarean section [98]. In dogs, as with all mammalian species, the mother-
newborn bond is crucial for the suitable development of maternal behavior that guarantees
offspring survival. In dogs, both natural birth and assisted delivery might be a stressful
and painful experience, which could affect the way a bitch cares for her litter [99]. A
female in pain may present a weaker maternal instinct and refuse to care for or feed her
puppies. This, in turn, puts them at risk of developing hypoglycemia and hypothermia,
both very dangerous in newborns [100,101]. However, when administering analgesics
to the bitch, one must be aware of their ability to pass through the mammary gland into
milk. The most commonly used analgesics belong to nonsteroidal anti-inflammatory drugs
(NSAID) or opioids [101]. Due to the risk of damaging the immature kidneys and liver
of the newborns in the case of using NSAID, or being more sensitive to the sedative and
respiratory depressant effects of opioids, especially in pups under three weeks of age, not
many drugs are approved for use in pregnant and lactating bitches, significantly affecting
their post-surgical recovery and welfare [101]. Studies have shown that cimicoxib and
carprofen exhibit low penetration through the mammary gland barrier [101,102]. Treatment
of lactating bitches for a short period of time seems to be safe for the offspring; however,
carprofen should be used with caution in bitches with diagnosed mastitis, in which case
the drug can penetrate the milk in higher amounts [101].
All of the previously mentioned issues are only a fraction of the knowledge necessary
to ensure a safe pregnancy outcome and the health of the litter. In the case of emerg-
ing complications, the correct diagnosis and prompt treatment are essential. Providing
proper care for both the mother and the offspring would significantly reduce the risk of
neonatal mortality.

4. Newborn’s Related Factors

Birth is the moment of fetal-to-neonatal transition which requires very complex adap-
tive changes which need to occur in a short period of time. Adaptation failures will result
in newborn compromise and homeostasis disturbances, and will determine the success of
its rearing. During the transition period, the neonatal condition is self-occurring or caused
by factors beyond the newborn’s control, but also the health status and behavior of the
mother, as well as improper care and environmental conditions, may play a role in the
newborn’s welfare and development [92,103].

4.1. Fetal Congenital Malformations

An important issue that can affect intrauterine life or the health status of the newborns
is the presence of congenital malformations. The canine congenital malformations are
structural or functional abnormalities present at birth that may interfere with the viability
of newborns, thus contributing to neonatal mortality [89,104]. They can be caused by genetic
factors, inherited and/or breed-related, or exposure during pregnancy to teratogenic agents
(toxins, chemicals, irradiation, or excessive supply of vitamins A and D) [104]. Studies that
examine the frequency of malformations have shown that the most common ones include:
cleft palate (2.8%), hydrocephalus (1.5%), anasarca (0.7%), cleft lip (0.6%), polydactyly
(0.5%), segmental intestinal aplasia (0.4%) or atresia ani (0.4%), and others [104]. The pups
with diagnosed malformations in the above study were 6.7% of 803 animals examined. The
mortality rate caused by these abnormalities among the pups during the first two days of life
Animals 2022, 12, 1402 14 of 26

was recorded at 61.4%, while from day 3 to day 30 it was 38.6%. In the vast majority of cases,
single malformations were present [104]; much less frequently, simultaneous occurrence
of two or more in one fetus was observed [105]. The risk of malformations is much more
common in pedigree dogs, and the brachycephalic dogs are among the most predisposed
breeds [2,21]. The accumulation of genetic defects over the years due to inbreeding or
selective breeding leads to reduced genetic diversity and increased predisposition of these
animals to present anatomical anomalies [10]. However, not all anomalies are associated
with an increased risk of mortality. For example, puppies born with additional fingers
(polydactyly) are unlikely to suffer from other health problems. The vast majority of
congenital malformations do, however, have a marked effect on longevity; in the case of
anasarca, hydrocephalus, cleft palate, atrophied intestine fragments, or atresia ani, the life
span will be substantially affected. Puppies with a cleft palate often develop aspiration
pneumonia due to milk entering the airways during sucking [106]. Those with intestinal
fragment atrophy are unable to pass meconium and feces, which initially leads to painful
constipation and over time death [107]. For some anatomical malformations, surgical
correction may be considered. For example cleft palate surgery [106,108] and surgical
operation of the posterior gastrointestinal obstruction [107,109] have been reported with
variable success. However, in most cases and with significant severity of defects, euthanasia
of affected puppies is often chosen to avoid unnecessary suffering.
The diagnosis of malformations is often difficult and many of them remain undetected
mainly due to a lack of clinical examination or inaccurate clinical examination or the initial
absence of clinical signs. Investigation of malformations in newborns immediately after
birth is fundamental because an early diagnosis of these conditions could lead to timely
clinical interventions and help to minimize mortality.

4.2. Birth Weight

Birth weight that reflects intrauterine growth is one of the most important determinants
of neonate survival [103,110]. Puppies weighing 25% less than the average weight of a
newborn in the given breed are suspected to have a significantly higher mortality rate [111].
The risk of death for puppies characterized by low birth weight is 12 times higher compared
to other newborns of normal birth weight from the same litter [112]. Low birth weight
is usually followed by fetal immaturity that limits the adaptation of the newborn to the
postnatal environment. Such puppies in comparison to average neonates of the same
litter have a lower ability to maintain proper body temperature due to a higher body
surface/weight ratio and are prone to hypothermia [113]. Moreover, puppies with low
birth weight have reduced energy supplies, are less vigorous, and as a result, cannot
compete with the rest of the puppies in suckling and thus do not take a sufficient amount
of colostrum, which makes them prone to hypoglycemia and dehydration [103,111]. As
a result, such newborns would be susceptible to developing growth and neurocognitive
deficiencies, cerebral palsy, intracranial hemorrhage, sepsis, hyaline membrane disease,
apnea, and retrolental fibroplasia [114].
Factors that influence birth weight could be classified as maternal, fetal, and placen-
tal [115]. Dam size, weight, body condition, age and breed, environmental conditions, as
well as litter size were described as important variables that affect fetal weight [103,116].
Due to the fact that birth weight reflects intrauterine nutrition of the fetus, the condition
of the placenta is one of the basic factors affecting the newborn [113]. Numerous studies
have been carried out on human and other animal species that provide information on the
relation between the birth weight and placenta [117–121]. Several studies were conducted
on dogs [113,122]. In small and toy breeds, authors revealed a positive correlation between
the birth weight of a puppy and the placental weight and its total area [113]. The total area
of the placenta, transfer zone area, and total vascular area were also proven to correlate
strongly with the placental weight [113]. The research focused on the histological exam-
ination of the placenta revealed that necrosis was a frequent finding in dogs. However,
it was shown that only multifocal-confluent necrosis was associated with a higher risk
Animals 2022, 12, 1402 15 of 26

of newborn death [122]. The placental examination should always be considered as it

may provide prognostic information about the puppy’s future development. However,
further investigation on a larger scale on breeds from the remaining groups should still be
carried out.

4.3. Noninfectious Conditions in Newborns

All newborns deserve great attention at this critical moment shortly after birth. The birth
weight and daily gains should be carefully recorded during the first weeks of life because
adequate growth reflects the puppy’s vitality, health, and proper development [103,111].
Stasis in weight gain is often the first alarming signal in the case of most neonatal diseases. It
indicates that the newborn is, for some reason, weakened and does not take enough food [92].
The body of a newborn dog works very differently from an adult dog’s body. It is
worth noting that in almost every case, the particular disorders of homeostasis in newborns
occur together and their symptoms overlap.

4.3.1. Hypoxia
Hypoxia is the first emerging state responsible for 60% of all neonatal deaths. The
oxygen deficits in neonates usually start from the dysfunction of umbilical circulation that
can be caused by prolonged and/or complicated parturition, i.e., umbilical cord vessel
compression or rupture, as well as too early placental detachment while a puppy is still in
the birth canal [92]. In addition, it was reported that puppies born in posterior presentation
were more susceptible to respiratory and metabolic acidosis than those born in anterior
presentation [123]. Furthermore, administration of oxytocin, anesthetic agents, surgical
preparation, and the cesarean section may also contribute to newborn hypoxia [92]. Mildly
hypoxic neonates are able to shift circulating blood from intestines, kidneys, spleen, or
skin and towards heart, brain, diaphragm, and adrenal glands. Severe oxygen deprivation
decreases fetal heartbeat, leading to tissue hypoxia and ischemia and finally multiorgan
failure. Affected puppies are more prone to amniotic fluid aspiration, and their mucous
membranes become less resistant to the pathogens’ penetration [92].

4.3.2. Hypothermia
The next noninfectious condition that may threaten the life of the newborn is hypother-
mia. Immediately after birth, any neonate is introduced into the adversely cool environment
in comparison to the intrauterine conditions [111,124]. The cooling sensation is escalated
by the amniotic fluid residuals. Hypothermia could lead to a significant drop in the heart
rate (200–250 bpm at 35.6 ◦ C vs. 40–50 bpm at 21.1 ◦ C), respiratory rate decrease, and
loss of suckling reflex, which in turn can cause dehydration and gastrointestinal disorders.
Such puppies would be much more susceptible to infections (e.g. herpes virus, bacteria,
and opportunistic pathogens) [92]. As thermoregulation is not fully developed in newborn
puppies and they are not able to shiver until day 7 of life, to compensate for the temperature
loss, they can only use the high energy-consuming thermal conduction [111]. Therefore,
the body temperature of a puppy strictly depends on the efficiency of the mother’s care. If
the dam’s maternal instincts are inadequate, the proper room temperature and additional
heat sources are essential for puppies’ survival [111].

4.3.3. Hypoglycemia
Hypoglycemia might be the consequence of the low core temperature or occur sepa-
rately with the suckling failure due to a variety of reasons. A neonate is born with immature
liver and the energy stored as hepatic glycogen is usually enough only for the first day of
life [92,125]. Moreover, some factors such as mother’s malnutrition or insufficient nutrition
during pregnancy could reduce the newborn’s glycogen supplies. Within 8–12 h after being
born, a puppy is forced to rely on colostrum/milk intake to maintain the proper glucose
blood level. Reduced or no food intake would result in rapid glycogen reserves depletion
and the development of hypoglycemia with typical symptoms of nervousness, vocalization,
Animals 2022, 12, 1402 16 of 26

irritability, and intense hunger that, if not corrected, would be followed by lethargy, mental
dullness, depression or stupor, seizures, tremors, and finally the death of the puppy [92]. It
is worth noticing that the severity of hypoglycemia symptoms does not always correspond
to relatively low blood glucose levels. Moreover, the clinical condition reflects the puppy’s
energy reserve. That explains why empirically based treatment with intravenous or oral or
glucose in many cases does not lead to a clinical improvement in the neonate [123].

4.3.4. Dehydration
Dehydration represents another homeostatic disorder which is usually a result of a
non-properly functioning excretory system, but can also occur with inadequate milk intake.
Newborn’s kidneys are not fully developed at birth and need a minimum 2–3 weeks to
undergo nephrogenesis to become fully functional [111,125]. The early kidney filtration is
characterized by a slow clearance of fluids, increased sodium loss, and, most importantly,
the inability to conserve water. That is why neonates are extremely susceptible to dehy-
dration [111]. It is important to remember that water turnover rate in pups is double than
in adult dogs and they demand an intake of approximately 132–220 mL/kg/day [111].
Usually, a sick puppy, independently of cause, brought to a veterinary clinic presents a set
of common symptoms such as low body temperature, malnutrition, and dehydration [111].

4.4. Neonatal Diarrhea

Neonatal diarrhea most commonly results from improper postnatal care and nutrition;
however, it can also be caused by infectious agents, especially in the case of high pathogen
exposure or adverse environmental conditions. The most common cause of non-infectious
diarrhea is overfeeding the puppy or offering unsuitable food [92,126]. Most often it
is noted in orphaned puppies and underfed neonates, which require complementary
nutrition [92,126]. Thus, it is essential to choose a well-composed milk replacer and carefully
calculate the intake for the puppy weight, according to the following rule: 20% of actual
body weight per 24 h divided into 6–8 portions [92]. Poorly balanced diet, wrong feeding
schedule, or inaccurate amounts would contribute to illnesses and other health problems.

4.5. Passive Immune Transfer and Colostrum Intake

It has to be remembered that the primary reason for the majority of postnatal disor-
ders is the insufficient consumption of colostrum, and thus ineffective passive immunity
transfer [14,127,128]. Only 10–20% of the mother’s IgG goes through the endotheliochorial
placenta in dogs. However, other authors report that puppy serum IgG concentration before
colostrum intake contains only 5% of immunoglobulins G compared to adult dogs [129].
The colostrum intake immediately after birth is essential for neonatal survival, development,
and further health [130]. Colostrum, apart from IgG, IgA, and IgM, essential for passive
immunity of a newborn, also contains nutrients, lysozymes, lactoferrins, white blood cells,
cytokines, hormones (cortisol, insulin, thyroxin, somatotropin, growth hormone), specific
microbiota, and several growth factors (insulin-like growth factors, epidermal growth factor,
nerve growth factor), all needed for proper development [61,129,130]. The most important
factor in colostrum intake is the time of ingestion which should not be later than 12–16 h
of life [61,130]. This limitation is an effect of neonate digestive wall differentiation. From
the moment of birth up to 4 h of life, around 40% of colostrum immunoglobulin (Ig) could
be absorbed. This ability decreases gradually up to 12–16 h after parturition, when the
junctions between enterocytes become tight and the intestinal wall becomes impermeable
for Ig and thus its absorption is not possible any longer [130]. Since the sufficient intake of
colostrum controls the risk of newborn puppies’ mortality, colostrum deprivation greatly
increases the risk of necrotizing enteric disease and septicemia [130].
In the case of the lack of colostrum or its insufficient supply, puppies need to be
hand-reared using commercial or homemade milk replacer. However, balancing the for-
mula to cover the needs for nutrients, energy, and volume might be quite challenging,
especially for the homemade one. Breeders can also look for a foster dam with a litter of
Animals 2022, 12, 1402 17 of 26

similar age to ensure sufficient immune protection [130]. It was also reported that the oral
administration of canine serum immediately after birth resulted in sufficient protective
IgG level (2.3 g/L) in puppies’ serum [131]. It is recommended that plasma donors live in
the same environment. Moreover, promising results were obtained with the use of serum
containing specific antibodies against common canine pathogens [131]. Many products
are available on the market; unfortunately, no milk substitute can completely replace the
colostrum or natural milk. Immunoglobulins present in some of the formulae can, to some
extent, replace the effect of colostrum by coating the intestinal epithelium and creating
a barrier against pathogens’ adhesion and translocation to the bloodstream [131]. Some
authors also suggested the establishment of dog colostrum banks, similar to farm animals’
husbandry [131].

Toxic Milk Syndrome

Another non-infectious risk factor which could appear in newborns is toxic milk
syndrome (TMS), caused by the milk being contaminated with bacterial toxins [132]. The
most common cause of TMS is acute mastitis or metritis present in dams [132]. Toxic
milk syndrome usually affects puppies from birth to two weeks of age. The pups become
weak and cry intensively. In most cases, diarrhea and intestinal gas accumulation occur.
Frequently, due to intensive diarrhea, the puppy’s anus becomes red and swollen. In the
authors’ own observations, often the strongest and the most eager to suckle puppies are
affected first. If TMS is suspected, suckling should be immediately discontinued, puppies
should be fed with milk replacer, and suitable treatment in a dam should be started.

4.6. Maternal Care

Dam’s behavior after parturition is strictly related to the offspring’s survival, and
the lack of effective maternal care exposes pups to environmental factors dangerous to
their health [133,134]. The most common signs of maternal neglect are behavioral: the
refusal to permit nursing or abandoning the litter; and physiological: the complete lack
of lactation or insufficient lactation. For that reason, the most common effect of maternal
neglect is initially hypothermia followed by hypoglycemia and dehydration [92]. On the
other hand, some bitches may present excessive maternal behavior characterized by very
intense licking and cleaning, which could also lead to hypothermia of a newborn [133].
Breeders can be assured that in abandoned puppies, accurate environmental conditions,
scrupulous nurture, and suitable diet should be sufficient to raise a healthy litter. It should
also be remembered that maternal care is essential not only for puppies’ health, but also for
their socialization and behavioral development [133].
The most important conclusion regarding postnatal factors interfering with puppy
survival is that most of those factors could be avoided with proper and conscious postnatal
care. That is why understanding the mechanism of neonatal problems is essential for
successful breeding [103].

5. Infectious Factors
A physiologically immature puppy without proper neonatal care will be more prone
to suffer from inadequate colostrum intake, and thus will have deficient immunity and
increased risk of infection. A bitch may come into contact with different microorganisms at
different stages of life. The outcome of pregnancy and the viability of the offspring are most
influenced by dams’ immunization (vaccinations), mating hygiene, care during pregnancy
and perinatal period, as well as the conditions in which the mother and her puppies are
housed for the first few weeks of their lives. Infectious agents are considered the second
main cause of a high mortality rate after dystocia [92]. Microorganisms can be transmitted
from bitch to pups during pregnancy through the placenta, during delivery, and later from
vaginal and oronasal discharges, feces, urine, or milk [135].
Animals 2022, 12, 1402 18 of 26

5.1. Bacterial Agents

Bacterial agents most commonly found in pregnancy loss and increased neonatal death
include Escherichia coli, Staphylococcus spp. and Streptococcus spp., and Klebsiella pneumoniae [92,
135–137]. Those detected less frequently include bacteria such as Brucella canis, Proteus mirabilis,
Pseudomonas aeruginosa, Mycoplasma spp., and Campylobacter jejuni [138–142]. Their presence
can be associated with abortion, stillbirths, reduced neonatal viability, and even temporary
or permanent infertility in adult animals [135]. In the course of most bacterial infections,
septicemia is considered the leading cause of death in puppies under 21 days of age [135]. The
course of the disease is usually hyperacute and the death occurs shortly thereafter. However,
subacute cases have also been observed [4]. The care of a newborn suffering from septicemia is
very difficult due to the very vague clinical signs and the rapid progress of the disease, which
significantly hinders diagnostic and therapeutic efforts; hence, the prognosis in such cases is
very cautious [92]. Among many indicators reviewed for their usefulness in the assessment
of mortality risk, the viability assessment carried out using the modified APGAR scale and
the colostrum intake measured by blood glucose concentration during the first 24 h of life
has proven to be useful for canine neonates [4,94]. It should also be mentioned that ticks
can be a source of infection with dangerous bacteria. Cases of fetuses being infected by their
mother suffering from tick-borne diseases caused by the Anaplasma platys bacterium have
been documented [143,144]. The detection of bacterial DNA in newborn pups of seropositive
dams in the absence of clinical signs is suggestive of the ability of the bacterium to cross the
placental barrier. Moreover, its capability to infect fetuses as early as the first half of pregnancy
has also been demonstrated [143]. More research is needed to determine the effects of infection
during the fetal period on the life and health of the offspring, as well as to raise awareness
among vets and owners to administer appropriate bacterial prophylaxis to their pets.

5.2. Viral Agents

Viruses are a common cause of reproductive failure in companion animals. Their small
size facilitates crossing the placental barrier, leading to pregnancy losses either by transpla-
cental transmission itself and direct infection of embryos or fetuses or, less frequently,
by severe debilitation of pregnant animals in the absence of congenital infection [145].
Canine parvovirus (CPV-1) and canine herpesvirus (CaHV-1), among others, are mainly
responsible for such problems. In the case of herpesvirus infection, litter size disproportion
often develops, neonates are born dead or weak, and mortality in the first 8 weeks of life is
usually high [146]. In the case of canine parvovirus infection, depending on the stage of
pregnancy in which the infection occurred, embryonic death and resorption are possible in
the early stages, while stillborn or weak pups are observed in the later stages. Acute infec-
tion in puppies in the first days of life is present with vague general signs (no food intake,
hypoglycemia, fever) and usually soon leads to the puppy’s death [147]. The morbidity of
the virus is usually 100%, and mortality among puppies younger than 6 months without
medical treatment reaches 91%, which can be reduced with suitable treatment [148]. The
effective management of viral infections in breeding dogs is primarily based on extensive
preventive measures. Various immunization protocols are available, including vaccination
against canine parvovirus [149] and canine herpesvirus [146]. Vaccination is the most effec-
tive way to control the spread of both infections in dogs and to prevent the development
of clinical forms of diseases. Vaccination eliminates the risk of infection during and after
pregnancy, increasing the pup’s chances of survival.

5.3. Parasitic Agents

When talking about infectious factors, one cannot forget the problem associated with
infections with intracellular parasites such as Toxoplasma gondii and Neospora caninum.
Toxoplasmosis in dogs is much less common than in cats. Most often it leads to immuno-
suppression and the onset of neurological symptoms: seizures, nerve deficits, ataxia, or
paralysis can be evident [150]. Infection-prone pregnant bitches are a serious concern. Para-
sitemia can cause placentitis, followed by the spread of tachyzoites to the fetus, and can
Animals 2022, 12, 1402 19 of 26

cause miscarriage. Fetal resorptions and sudden infant death have also been reported [151].
T. gondii has also been isolated from pups of seropositive dams without clinical signs [150].
Toxoplasmosis is frequently associated with secondary infections in dogs. When combined
with viral infections, such as the distemper virus (CDV), it can cause the death of the
entire litter due to a complete immune failure in very young animals (up to 30 days of
age) [152]. The second intracellular parasite is the protozoan Neospora caninum [153]. Dogs
can be intermediate or definitive hosts, while infection occurs mainly through contact with
contaminated water or food containing cysts. The horizontal transmission of the parasite
from mother to fetus through the placenta is also possible [153]. Robbe et al. reported that
pregnancy might be a predisposing factor for the Neospora caninum infection, which usually
results in abortion or the birth of weak puppies that die shortly after [154]. In Australia, a
case of a bulldog litter born from a seropositive mother was reported, in which one of the
seven pups died from a multisystemic infection caused by Neospora caninum [155]. The pup
was the smallest of the litter and was reported to have signs of weakness, lack of sucking
reflex, and difficulty breathing. When necropsy was performed, diffuse pulmonary edema,
inflammatory changes in internal organs, and acute myocarditis were detected. Studies
conducted in Italy [154], Iran [156], Brazil [157], and Australia [158] indicated that parasitic
diseases in breeding dogs are underestimated and often overlooked despite the significant
prevalence of toxoplasmosis and neosporosis in the companion dog population. It should
be noted that they are related to the trend of feeding raw animal meat in the BARF diet,
which, at least for this reason, should not be recommended for feeding pregnant females,
as it can be a potential source of infection with these protozoa [159,160].

6. Conclusions
The neonatal period is a challenging time of adaptation for any puppy to life outside
their mother’s body. In our review, we have discussed a variety of factors that affect puppy
viability in the early stages of life. The order of discussion was guided by the natural course
of pregnancy, birth, and the neonatal period. The viability of puppies depends first on the
health of the mother and the environment that affects her in different ways, and then on
the maturity of the adaptive mechanisms developed by those puppies during embryonic
and fetal development.
For the early detection of the first signs of any emerging abnormality, the fundamental
factor is conducting examinations and observing the pregnant bitch. Regular ultrasound
and electrocardiographic monitoring enable rapid diagnosis of abnormalities, which, in
turn, increases the chance of effective implementation of therapeutic measures [5,78–82,84].
This is especially true in the case of potential perinatal complications, because the impact
of delivery on pup viability should always be kept in mind. The emergency cesarean
section carries far greater risks than natural birth or planned surgery, and delaying the
decision can often be fatal to the viability of the pups [5]. Therefore, the safest solution
would be a planned cesarean section in the case of bitches known to be prone to perinatal
complications, either due to breed predisposition or previous history. After the surgery, it is
necessary to perform a quick evaluation of newborns, usually using the modified APGAR
score [94] and the NVR [5], which are highly effective in identifying weak pups that require
special care.
The cesarean section is also a challenging procedure due to the adequate intra- and
postoperative care. For the safety of milk-sucking puppies, medications given to the mother
are often highly restricted. However, after all, they are essential for dams’ welfare and
could significantly reflect the quality of care a female provides for her puppies [100,133,134].
In the authors’ opinion, the problem of providing adequate analgesia protection to the bitch
after a cesarean section is urgent and certainly requires further research to improve current
surgical protocols. However, it should be remembered that once a puppy does not take
milk, especially not colostrum, the risk of developing immunity problems would increase.
Any factors that weaken a newborn’s immunity drastically increase its susceptibility to
Animals 2022, 12, 1402 20 of 26

infections. Thus, it is crucial to provide diligent care and hygiene for the bitch and her
offspring. The risk of certain infections can be reduced through regular vaccinations.
In conclusion, all collected information focuses on factors influencing the viability of
puppies during their most critical infancy period. The authors hope that this review would
be helpful both for scientists and practitioners to grasp the picture of the vastness of the
interrelationships during the perinatal period that determine neonatal health and welfare. It
should also be mentioned that canine reproduction currently focuses on pedigree dogs only.
Hence, inbreeding and focusing solely on exterior characteristics significantly increased
susceptibility to perinatal complications [10]. This leads to a situation observed more
and more often nowadays, where reproduction in some breeds, mainly brachycephalic, is
impossible due to their anatomy and physiology, without medical assistance performed
by veterinarians [21]. The ethics of such a practice is difficult to assess due to divergent
opinions among scientists, physicians, and breeders involved in small animal reproduc-
tion [17,161]. Cooperation between science and veterinary medicine can contribute to a
more effective accumulation of knowledge in the field of canine neonatology and thus a
further improvement in the quality of services provided.

Author Contributions: O.U.—writing and editing the manuscript; M.O.—conceptualization and

corrections of the manuscript; M.E.—writing the manuscript; W.N.—supervising and consulting the
manuscript. All authors have read and agreed to the published version of the manuscript.
Funding: The costs of publications were financed under the Leading Research Groups support project
from the subsidy increased for the period 2020–2025 in the amount of 2% of the subsidy referred to
Art. 387 (3) of the Law of 20 July 2018 on Higher Education and Science, obtained in 2019. The APC
is financed by Wroclaw University of Environmental and Life Sciences.
Institutional Review Board Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: Authors have no conflict of interest to declare.

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