Obstetic Anesthesia Maternal and Fetal Physiology 1. Maternal Alterations a. Neurological i. MAC decreased ii.

Epidural space becomes smaller iii. CSF volumes decreased and epidural veins engorged iv. increased sensitivity to local anesthetics b. Respiratory i. Net effect is increased ventilation 1. tidal volume increased ~40% at term 2. resp rate increased ~15% 3. minute ventilation increased ~50% a. PaCO2 decreased to 28-32 mmHg secondary to hyperventilation, i.e. resp alkalosis i. compensatory metabolic acidosis by excretion of bicarbonate maintains normal pH ii. Expanding uterus displaces diaphragm cephalad 1. FRC decreases by ~20% a. potential for small airway closure b. decreased FRC, coupled with increased maternal oxygen consumption, can rapidly lead to maternal hypoxia during induction of GA 2. no change to vital capacity or total lung capacity iii. Preoxygenation is mandatory prior to anesthesia induction! iv. Additional: 1. P50 of HgB increases from 27 to 30 mmHg a. aids delivery of oxygen to fetus 2. decreased physiological deadspace 3. Slight decrease in airway resistance 4. congestion of respiratory mucosa secondary to vasodilation a. use smaller ETT and avoid nasal intubation or instrumentation

c. Cardiovascular i. increased plasma volume (~45%) in excess of red cell mass (RBC vol increases ~20%), i.e. relative hypervolemia 1. RAAS: increased renin & aldosterone sodium/H20 retention ii. oxygen delivery is optimized 1. increased CO (up 40%; 15-30% from HR and 30% from stroke volume) 2. rightward shift of oxyhemoglobin dissociation curve iii. peripheral vascular resistance drops about 15% 1. increased progesterone relaxes venous smooth muscle iv. Changes in CO during Labor 1. preterm: profressive increase, then dramatic during labor 2. latent phase: 15% 3. active phase: 30% 4. second stage: 45% 5. postpartum: 80% (or higher, 100-115%) v. Other CV changes 1. response to adrenergic drugs blunted 2. cardiac hypertrophy can be seen on CXR 3. heart murmurs are often present on auscultation 4. decline in plasma colloid osmotic pressure vi. Supine Hypotension Syndrome (Aortocaval Compression) 1. ~20% of term parturients will develop hypotension, pallor, n/v, and diaphoresis when they lie flat. a. may be seen as early as 20 wks gestation 2. Txt: a. place patient in Lt lateral uterine tilt position b. supply O2 c. check blood pressure d. txt with fluid boluses/pressors PRN d. Hematological Changes i. Cell mediated immunity depressed ii. hypercoagulable state 1. high risk for pulmonary embolism 2. Coags and changes during pregnancy: a. Increased coag factors i. I, VII, VII, IX, X, XII b. Decreased coag factors i. XI, XIII c. Unchanged coag factors i. II, V d. PT and PTT decreased 20%

e. Renal Changes i. Renal blood flow and GFR increased by about 50% by 16th week, remains elevated until delivery ii. serum BUN and creatinine are mildly reduced iii. mild glycosuria and proteinuria are common f. Gastrointestinal Effects i. stomach displaced by uterus resulting in reduced competence of gastroesophageal sphincter ii. progesterone decreases gastroesophageal sphincter tone iii. placental gastrin secretion increases acid secretion iv. slowed gastric emptying is controversial v. net effect of all this is that parturients have 1. gastric fluid of >25 ml 2. pH of less than 2.5 3. increased risk of symptomatic aspiration vi. Hepatic 1. 20% decrease in pseudocholinesterase levels 2. simultaneous increase in volume of distribution counters any clinically significant prolongation of NMB with SCh vii. Gallbladder 1. decreased CCK release and contractile response creates sluggish GB and gallstones 2. FFFFF5 Fs a. Fat b. Female c. Forty d. Fair e. Fertile g. Endocrine i. relative insulin resistance results in higher plasma Glucose levels, allows for more fetal glucose transfer

2. Placenta Anatomy:

a. b. Transfer across the placenta i. modes 1. diffusion 2. bulk flow 3. active transport 4. pinocytosis 5. breaks c. Transfer of Gas i. oxygen transfer is dependent on maternal uterine blood flow vs. fetal umbilical flow ii. oxygen has the smallest storage to utilization ratio in the fetus 1. fetal stores are ~42ml of Ox and consumption is 21 ml/min 2. compensatory mechanisms (redistribution, anaerobic metabolism) the fetus at term can survive 10 min of total O2 deprivation iii. placental blood has a PaO2 of 40mmHg 1. to compensate for this, fetal oxyhemoglobin dissociation curve is left shifted and the maternal curve is right shifted

2. 3. Fetal Hb is also higher than maternal Hb iv. CO2 transfer occurs by simple diffusion across the placenta 1. fetal HgB has a lower affinity for CO2 than maternal d. Placental Circulation i. Uterine Blood Flow (UBF): 1. represents 10% of CO (600-700 mL per min in the parturient). 2. normally 50 ml per min in non-pregnant state 3. 80% of this blood goes to the placenta, the rest goes to the myometrium (to feed the uterus) ii. 3 factors influencing UBF 1. systemic blood pressure 2. uterine vasoconstriction 3. uterine contractions iii. Anesthesia and UBF 1. IV agents: a. propofol and thiopental mildly reduce UBF via maternal hypotension b. Ketaamine : no net effect at doses <1.5mg/kg 2. volatile agents a. decrease UBF d/t hypotension but at <1 MAC the effect is minor b. N2O has negligible effects 3. opioids have little effect 4. LAs/Neuraxial Anesthesia a. high serum local anesthetic levels can result in uterine vasoconstriction b. Uterine blood flow may improve with Neuraxial analgesia as a reduction in maternal catechol levels

reduces vasoconstriction, as long as normal BP is maintained. 3. Fetal Circulation

a. b. Events at Birth i. filling of lungs with Oxygen decreases pulmonary vascular resistance 1. (opposite of Hypoxic Pulmonary Vasoconstriction) ii. increased pulmonary flow and increased LV volume increases LAP and closes the foramen ovale iii. increased oxygen tension closes the ductus c. Hypoxia or acidosis will increase R to L shunting through the ductus creating a downward spiral 4. Labor in brief a. Normal Labor starts 40 +/-2 wks after LMP i. 1st stage: 1. onset of true labor until complete cervical dilation a. latent phase: minor dilation 2-4 cm, infrequent contractions

b. Active phase: progressive dilation to 10cm and regular contractions (3-5 min) ii. 2nd stage: 1. time from complete dilation until infant delivered iii. 3rd stage 1. time from delivery of infant until placenta delivered b. Decelerations: i. Early: 1. Normal: occur at peak of contraction 2. vagal response due to head compression by uterus ii. Late 1. Not OK: onset after peak of contraction and persistent 2. due to uteroplacental insufficiency iii. Variable 1. if persistent can be indication of C-section: onset variable (before/after) peak 2. due to umbilical cord compression by uterus

3.