Anesthetic Implications for the

Physiological Changes in Pregnancy &

Basic FHR Monitoring

J.E. Pellegrini, CRNA, PhD

Changes during the
Puerperium

Changes to anatomy & physiology

Most changes to physiology occur during
the 1st trimester
Most changes to anatomy occur during the
2nd and 3rd trimester
Many of the changes are beneficial
As an anesthetist you must have a good
understanding of these changes and so that you
can determine if they will have an impact on your
your anesthetic management
Physiological Changes of
Pregnancy
Primarily we’ll discuss:
Respiratory Changes
Cardiovascular
Changes
GI/Hepatic/Renal
Changes
Changes in Neural
network (metabolism)
 Factors influencing the
Respiratory System
and endotracheal intubation

Weight gain
Breast enlargement
Vascularity of the respiratory tract mucosa
Possible edema of the oropharynx,
nasopharyx, and vocal cords (**most
prevalent in preeclampsia)
Progesterone-beneficial
Respiratory System Changes

Lung Volume Changes abbreviation % Change

Total Lung Capacity TLC Decreased 5%

Vital Capacity VC No Change

Inspiratory Capacity IC Increased 5%

Expiratory Reserve Volume ERV Decreased 20%

Residual Volume RV Decreased 20%

Functional Residual Capacity FRC Decreased 20%

Closing Capacity CC No Change

Respiratory Changes with Pregnancy
 Compensatory Respiratory
System Changes
 Chest Expansion-expands anteroposterior
 FRC - decreased
FRC & CC differences  underventilated aveoli

 Airway closure - (-a DO2) occurs in 50% of all

parturients but hypoxemia extremely rare secondary to
increased vent & CO
  Residual Volume and ERV   tolerance for
apnea
 ABG Changes- reflect chronic hyperventilation
PACO2 32-34 mm Hg by 12 weeks gestation
Respiratory Alkalosis(7.44) HCO3, BE and buffer base 
More prone to metabolic acidosis during prolonged labor
secondary to pyruvate & lactic acid accumulation
 Compensatory Respiratory
System Changes
 Ventilation (8-10 wks gestation)
MV  50% at term ( 40% TV and 15% RR)
Helps decrease dead space component
 PaCo2 levels (respiratory alkalosis - 7.44)

 Hypoxia & Hypercarbia -develop rapidly with

obstruction, prolonged apnea or hypoxic gas mixture
PO2 can  80 mm Hg/min faster than non-pregnant 
• Due to  O2 consumption,  FRC,  C.O. &  tissue
extraction of Oxygen
  Airway Resistance
Effects of Progesterone
Chest wall but not lung compliance decreases
 Compensatory Respiratory
System Changes

  Oxygen Consumption 
20%
demands during labor
where it is estimated that
the avg. labor  jogging 12
miles
 Oxyhemoglobin
dissociation curve to the
right
 (P50 Values  from 26 to
28 mm Hg)
 Clinical Implications of these
Respiratory System Changes

Effects on Inhalation Anesthetics

Faster induction rate ( RR and C.O.)
MAC decreased by 30-40%
 MAC noted as early as the 8th week gestation
Effects of Maternal Hyperventilation
Constriction of umbilical and uterine vessels
 incidence of fetal acidosis
Can attenuate most responses with
adequate analgesia
Studies indicate that adequate pain relief (i.e. CLE can
normalize oxygenation &  MV & O2 consumption)
 Cardiovascular System

Blood Volume
 35% (plasma volume  50% & red cell mass  15%)
Blood loss usually well tolerated at delivery
See fall in Hct in Postpartum by approximately 5% secondary to
diuresis
Normally only have to consider blood after 1500 ml EBL

Cardiac Output
 30-40% in 1st trimester and 40-45% during labor
and 50-60% in immediate postpartum period
Prone to Aortocaval Compression
Changes in Cardiovascular System

VARIABLE CHANGE AVG CHANGE

Blood Volume * Increase *+ 35%
Plasma Volume * Increase *+ 45%
*Modifies
Transfusion
Requirement
Stroke Volume Increase + 20%
Heart Rate Increase + 40%
Femerol (Uterine) venous Increase + 30%
pressure
Total Peripheral Resistance Decrease - 15%
Mean Arterial Pressure Decrease - 15 torr
Systolic Blood Pressure Decrease 0 to - 15 torr
Diastolic Blood Pressure Decrease - 10 to - 20 torr
Central Venous Pressure -------- No Change
Aorto-Caval Syndrome
Hypotension
20 weeks gestation
Gravid Uterus Weight
Can Decrease C.O. 30%
Management Plan
Pre-induction hydration
Left Uterine Displacement (or RUD)
Ephedrine/Phenylephrine
Venal Caval Compression
Distention of epidural venous
plexus
Decrease LA dose 1/3 (>14 wks)
Cardiovascular Changes

90 90
Heart Rate (bpm)

Heart Rate

Stroke Volume
80 80 (bpm)

(ml/beat)
70 70
Stroke
60 60 Volume
(ml/beat)
50 50
0 8 16 24
Gestational Age
Anesthetic Significance of
Cardiovascular Changes

Venodilation- increases accidental epidural vein

puncture
Oxytocin with free H20  volume overload
 Hgb levels > 14 indicates low volume status,
HTN or diuresis
C.O. high in 4 hrs postpartum
B/P < 90 to 95 torr   uterine blood flow
Hypotension occurs 75% with T4 level
Gastrointestinal Changes
 Stomach displaced
upward and 45 to the
right & displaces the
intra-abdominal segment
of the esophagus into the
thorax decreased tone
of the lower esophagus
 incidence of pyrosis
 Delayed gastric emptying
  incidence of full
stomach
 Gastrointestinal Changes

Obesity - associated 2-20 fold  in mortality (PIH, IDDM)

Progesterone
 Gastrointestinal motility & esophageal sphincter
tone
Parturients beyond 18th week of gestation more
prone to vomiting and regurgitation
Treat as full stomach at 12th week
*put it all together and this spells trouble
 Other Compensatory
Changes
Renal System - GFR  60% at term
 in aldosterone and  plasma osmolarity (ADH
resetting)
 RBF   Creatinine clearance & a  BUN & Uric
Acid levels (½ to 2/3 that of normal)
Hepatic System
Usually no significant changes except slight  in level
enzymes and 2-4 fold  in alkaline phosphatase &
cholesterol (from growing placenta)
Slight  in plasma cholinesterase & serum albumin
Can see spider angiomata & palmar erythema (from
 estrogen levels)
Neuromuscular Changes

Endorphins
MAC  by 40%
Sedative Effect from Progesterone
Changes in SNS
See down-regulation
Altered Response to Catecholamines
 Altered Responses to
Anesthesia
 sensitivity of neural network
Probably secondary to  levels of circulating
progesterone
Possible influence from circulating endorphins
Applicable for both neuraxial and peripheral
blockades
Applicable for parturients beyond 24th week
gestation
Decrease local anesthetic dose by as much as 1/3
Sensitivity of Nerve Fibers with
Pregnancy
Time (min) to 50%

40
30 Pregnant
Block

Animals
20
Non-pregnant
10 Animals
0
A B C
Nerve Fiber
Summary

Multiple physiological changes in

pregnancy have profound impact on your
anesthetic management
The conservative approach is the best
approach when dealing with the OB
patient
Your principle patient is the parturient
Fetal Monitoring

No ideal way to assess fetal well-being

FHR one of the better methods
FHR influenced by Para and sympathetic
outflow
FHR responds to Baro & Chemo receptors
Maternal & Fetal Monitoring
Fetal Heart Rate


 Normal Baseline between 110-160/min

 Small square = 10 seconds
 Large square = 1 minute
 Baseline rate determined by rate between
contractions
Three Primary Mechanisms that
Uterine Contractions cause FHR
Abnormalities
FHR Accelerations

The FHR will normally remain steady or

accelerate with uterine contractions
Typically viewed as a reassuring phenomenon
Early Decelerations

 Begins with onset of contraction & ends at the

conclusion of contraction (with return to baseline)
 Typically caused from Head Compression & routinely
not viewed as a sign of fetal distress
Late Decelerations

 Transitory Decreases in FHR caused by Utero-Placental

deficiency (hypoxia) indicating the fetus is not able to
withstand the uterine contractions
 Persistent Late Decelerations are considered an
ominous sign especially when associated with loss of
short term variability
Nonreassuring Patterns
 Nonreassuring, or "warning," patterns suggest decreasing
fetal capacity to cope with the stress of labor.

 Nonreassuring Patterns (Warning Signs)
  Decrease in baseline variability
  Progressive tachycardia (>160bpm)
  Decrease in baseline FHR
  Intermittent late decelerations with good variability

 Ominous patterns suggest possible fetal compromise.

Ominous Patterns

  Persistent late decelerations, especially with

 decreasing variability
  Variable decelerations with loss of variability,
 tachycardia, or late return to baseline
  Absence of variability
  Severe Bradycardia
Treatment for FHR Abnormalities
Pattern Cause Treatment

Bradycardia, Hypotension IV fluids, ephedrine (or

Late phenylephrine) change
Decelerations position

Uterine Decrease Oxytocin

Hyperstimulation
Variable Umbilical Cord Change Position
Decelerations Compression
Head Continue pushing if
Compression FHR variability good

Late Decreased Change position &

Decelerations Uterine Bloodflow apply oxygen

Decreased Prolonged Change position &

Variability Hypoxemia apply oxygen
So – In summary

If an ominous pattern appears to be

present:
Have the mother lie on her left side or in a
knee chest position immediately followed by:
Increase IV fluid.
Give her oxygen @ 10-12L to breathe by mask.
Discontinue or decrease any CLE infusion
Notify the obstetrical nursing staff & Obstetrician
Pellegrini@son.umaryland.edu