Dr Matthew Ho

BSc(Med) MBBS(Hons) FANZCA

Maternal, Foetal & Neonatal Physiology

Physiol-10B13/07B14/01A4/97B8 Describe the cardiovascular changes in the neonate that occur at

birth.

1. During the process of birth, the foetal circulation undergoes significant and sequential change
which involve interaction between the respiratory and cardiovascular systems:
a. Foetal circulation: consists of 2 parallel circulations –
i. RV  pulmonary artery  ductus arteriosus  lower limbs  SVC
ii. LV  blood through FO  aortic arch  head, neck and upper limbs 
umbilical a
iii. Pulmonary circulation high pressure, low flow
b. Adult circulation:
i. consists of 2 series circulations
ii. pulmonary circulation low pressure, high flow

2. Circulation changes:
a. Cessation of umbilical blood flow
b. Closure of ductus venosus
c. Closure foramen ovale
d. Closure of ductus arteriosus
e. Increase in pulmonary circulation

3. Associated respiratory changes:

a. Loss of placental gas exchange
b. Initiation of ventilation
c. Commencement of pulmonary gas exchange

4. Mechanisms:
a. Passage through the birth canal:
i. Expulsion of 35mL fluid from foetal lungs
ii. Exposure to external stimuli (noise, light, cold)  stimulation of respiratory
centre
b. Compression of umbilical vessels / clamping of cord –
i. Vasoconstriction of umbilical vein
ii. Relative foetal hypoxia  peripheral and central stimulation of respiratory
centres
iii. ↓ flow to ductus venosus  closure  ↓ preload to RA
iv. Loss of low resistance placental circulation  ↑ LV afterload
c. Onset of breathing:
i. Radial traction of extra-alveolar vessels  ↓PVR
ii. ↑O2 lungs  loss of pulmonary hypoxic vasoconstriction  ↓ PVR
iii. Starling’s forces move fluid from interstitium  pulmonary vessels
iv. ↑ pulmonary blood flow  ↑ VR to LA
d. Change in R and L heat pressures: above changes cause ↓ pulmonary vascular
resistance, ↓ RA pressure (↓ VR), ↑ LA/LV pressure (↑ afterload)
i. LA pressure > RA pressure  closure of foramen ovale  removal of R  L
shunt
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

ii. ↑ Aortic flow  ↑ Aortic pressure > pulmonary a pressure  ↑pO2 aorta  ↓
prostaglandins E1/2  closure of ductus arteriosus (pressure and chemical
mediation, takes 10-15 hours)

5. Summary:
a. Other changes:
i. ↑ renal BF
ii. Change skin BF
b. Many changes initially reversible  transitional circulation
i. ↑ RAP  open PFO
ii. ↓ PVR  open PDA
c. Overall  parallel  series circulations
i. Shunt closure
ii. ↑ pulmonary circulation
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

Physiol-MAKEUP Describe the first few breaths at birth

1. Neonatal lung ventilation replaces placental gas exchange during the process of birth. The first
few breaths are integral in initiating this process.

2. Foetal lung:
a. Full of fluid 20mL/kg  relatively non compliant

3. Mechanisms promoting breathing:

a. Passage through birth canal  squeezing of compliant chest wall  expulsion of foetal
lung fluid.
b. Exposure to external stimuli  stimulation of respiratory breathing centre

4. Pressure vs. Volume curve

a. Before the first breath, there is no air in the lung  volume 0
b. First breath: large negative IT pressure (-50-60cmH2O) required to inflate lung with air
(due to ↓ compliant)
c. Subsequent breaths: ↑ air/liquid interface + surfactant  improved lung compliance --<
each breath becomes easier
d. FRC: as lung inflates, FRC rises rapidly –
i. 17mLs/kg 10min
ii. 30mLs/kg 30-60min

5. Clinical importance:
a. Rapid improvement in ventilation required to supply ↑ O2 needs by the neonate
(7mLs/kg  2x adult)
b. Achieved by ↑↑ RR, CO
c. O2 demand highly dependent on temperature (thermoneutral zone narrow).
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

Physiol-09B10 Compare and contrast the neonatal respiratory system with the adult.

1. The neonatal period is defined as the first 28 days of life, and significant consideration must be
given to physiological differences in the respiratory system with the adult.

Parameter Neonate Adult Clinical correlation

Anatomy
Upper airways Narrow nasal passages Nasal blockage can cause respiratory distress
(contributed 50% AWR)
Larger tongue
Obligate nose breathers
Larynx Longer U-shaped epiglottis Neonates use straight blade laryngoscopy
Glottis cephalad at C3-4 Backward pressure helps better visualised larynx
(adult C5-6) and angulated
anteriorly Don’t used cuffed tubes on neonates
Funnel airway with
narrowing cricoids
Lower airways Shorter trachea (4-5cm) Easier to intubate R main bronchus
Narrow trachea Sensitivity to tracheal oedema
R main bronchus Bronchospasm rare cause for airway obstruction
straighter (30 degrees) Poor bronchodilator response
Paucity of smooth mm
Ventilation
RR 30-40 10-15 More efficient to ↑ RR than ↑ TV as time
TV (mls/kg) 7 7 constants are short in the neonatal lung.
VD (mls/kg) 2.2 2.2
VD / VT 0.3 0.3 O2 consumption higher due to ↑ BMR  need
Alveolar Vent 120-140 60-70 ↑ ventilation, cardiac output
(mls/kg/min) ↓ O2 reserve for pre-oxygenation
O2 consumption 6-7 3-3.5
(mls O2/kg/min)
Spirometry
FRC (mls/kg) 30 30 Normal respiratory  closure of small airways
Closing capacity > FRC (↓ outward chest < FRC  gas trapping  ↓V/Q (0.4)  ↑ mismatch,
recoil, ↓ inward lung venous admixture  ↑ A-a gradient
recoil)
A-a gradient 30 5
(mmHg)
PaO2 (mmHg) 50-70 100
Mechanics
Chest wall High compliance Less thoracic breathing
Compliance
Lung compliance same same
Thoracic breathing Horizontal ribs  less
bucket handle
Diaphragm ↑ importance for ↑ affect if diaphragmatic splinting from
breathing. abdominal distension
↓ oxidate type I muscle ↑ susceptibility to fatigue
fibres
Control
Response CO2/O2 Mature
Depressed hypothermia
Periodic apnoea Common 5-10 sec
Abnormal 20 sec 
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

bradycardia
Peripheral circulation
Hb (g/dL) 170  140 120 Neonatal blood has 1.25x O2 carrying capacity
HbO2 dissociation HbF 75% with higher HbA
affinity lower
affinity
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

Physiol-MAKEUP Why are neonates more susceptible to change in external temperature? Describe
the neonatal temperature regulation mechanisms.

1. Neonates have important anatomical and physiological differences from the adult which results
in a different (and reduced) ability to regulate internal body temperature at 37 degrees. Under
usual circumstances, the body maintains temperature at 37 in cooler ambient temperatures by
balancing heat production (by BMR) and heat loss.
Neonates have a reduced thermoneutral zone – the ambient temperature range in which body
temperature is maintained with minimal heat production (and O2 consumption).

Neonates  32-34 degrees  lower temperatures require ↑ heat production

Adults  25-30 degrees

2. Factors affecting ↓ neonatal heat regulation:

a. Larger BSA/weight ratio (3x adult)
b. ↓ insulating capacity of subcutaneous tissue
c. Limited sweating capacity
d. Limited shivering capacity

3. Forms of Heat loss:

a. Radiation 39% - heat loss to ↓ environment temperature, ↑ with ↑ BSA
b. Convection 34% - transfer by movement of surrounding air
c. Evaporation 24% - from sweating and respiratory tract. Neonatal sweating is limited.
d. Conduction 3%

4. Mechanisms of response to cold: hypothermia is not easily corrected in infants and relies on ↑
O2 consumption if temp ↓ thermoneutral zone  hypoxia.
a. Behavioural changes: crying, muscular activity
b. Skin vasoconstriction
c. Non-shivering thermogenesis: brown fat is abundant in neonates (2-6% weight) and
found in abdominal locations, large blood vessels , interscapular regions and the base of
the neck. Unlike white fat, it is rich in mitochondria and innervated by sympathetic fibres
via β3 receptors  oxidative phosphorylation, lipolysis, β-oxidation, and glycolysis  ↑
heat production.
d. Shivering: poorly developed

5. Mechanisms of response to heat

a. Behavioural: crying, moving clothes, lethargy
b. Skin vasodilation
c. Sweating: poorly developed
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

Physiol-08A12/01B4/95A8 Describe the physiological changes that occur in respiratory function

during pregnancy and what significance these changes have to anaesthesia.

1. Pregnancy markedly alters respiratory physiology through changes in hormonal, mechanical, and
metabolic factors (↑BMR 20%).

2. Anatomical changes:
a. Diaphragm moves up 4cm due to mechanical splinting and cephalad movement of intra-
abdominal contents
b. Thoracic cage ↑ AP and transverse diameters (2-3cm) due to actions of relaxin (corpus
luteum) on ligaments.
Overall, the thoracic cage volume remains relatively unchanged.
c. Large airways:
i. ↑ anatomical dead space 35%, but VD/VT constant 30%
ii. Capillary engorgement: vocal cord enlargement and oedema
3. Spirometry: changes significantly manifest after 20 weeks. Closing capacity and flow volume
curve are unchanged.

Volume (mls) Non-pregnant Pregnant

TLC 4150 3950
IRV 2000 2000
TV 450 600
ERV 700 550
RV 1000 800
FRC 1700 1350

4. Ventilation: progesterone secretion (placenta) stimulates the respiratory centre

a. TV: ↑ 40% at term
b. RR: ↑ 15%
c. MV = TV x RR  ↑ 50%
d. Lung compliance unchanged, chest wall compliance ↓ 20-30%

5. Arterial blood gas: changes caused by hyperventilation

a. pCO2: ↓ 26-32mmHg  respiratory alkalosis
b. physiological compensation: renal excretion of HCO3 brings pH down to normal range.
↓HCO3 18-21mmol/L
c. O2 dissociation curve remains unchanged:
i. ↓ pCO2 shifts left
ii. ↑2,3 DPG and ↓HCO3 shifts right
d. pO2 ↑ (hyperventilation)  100-105mmHg, but not much change in O2 content due to
saturation of Hb

6. O2 flux = CO x O2 conc (Hb x sats x 1.34). Overall, O2 consumption ↑ 15-20% due to demands of
foetus, maternal tissue hypertrophy, and ↑ work of breathing.
a. CO  ↑ 30%
b. Hb ↓ 15-20%
c. O2 flux overall ↑ 20% to meet ↑ metabolic demands of mother and foetus

7. Labour: stimulation by pain, and ↑ metabolic demand (uterine O2 contractions)

a. MV ↑ 70%, hyperventilation  hypocapnoea
b. Uterine relaxation produces brief hypoventilatory pauses  transient hypoxaemia
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

8. Clinical implications:
a. Reduced FRC, ↑ metabolic demand  ↓ preoxygenation, ↑ susceptibility to hypoxia
b. Reduced MAC
c. More difficult intubation
d. ↓ buffering capacity
e. Low pCO2 facilitates ↑ gradient for CO2 exchange across placenta
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

Physiol-MAKEUP Describe the physiological changes that occur in cardiovascular function during
pregnancy.

1. Pregnancy has significant effects on the cardiovascular system. Overall, ↑ stress due to
metabolic demand and mechanical effects.

2. Cardiovascular parameters –

Property Maximum change Peak effect

Cardiovascular – addition of placental circulation ↓ SVR (AV shunt)
HR ↑ 25% 30 weeks
SV ↑30% 25 weeks
SVR ↓35% 20 weeks
CO ↑50% 30 weeks
VR ↑50% 30 weeks
MAP ↓ 10% 20 weeks
PVP Unchanged
Blood volumes
Intravascular ↑40% Term
Plasma ↑45% Term
RBC ↑20% 20 weeks
Haematocrit ↓50% Term
Regional blood flow
Placental 750mL/min Term
Renal ↑80%
Skin ↑
GI ↑
Brain Unchanged
Blood constituents
Na, K, Cl ↓ slight
Albumin ↓ (dilution)
Oncotic pressure ↓ Predispose oedema
Clotting factors ↑ I,VII,VIII,IX,X
ATIII ↓
Pseudocholinesterase ↓ 30% dilution

3. Aorto-caval compression: uterus compresses the IVC when patient is supine (affects 15%
women)
a. Compression  compress IVC  ↓ VR  ↓ CO
b. VR diverted via collaterals through epidural  azygous veins
c. Aortic compression  ↓ uterine BF  ↓ placental perfusion
d. Treated by lying patient on L side

4. Labour:
a. Contraction uterus  300mL blood released into circulation
b. ↑ work contraction  CO ↑ 45% during delivery
c. MAP ↑ 20% during contraction
d. Following expulsion – CO 60-80% above normal values due to autotransfusion and ↑VR
from uterine involution.
5. Clinical:
a. ↑ HR/SV  ↑ work  ↑ risk CCF, APO
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

b. ↑ venous plexus vol during labour  ↓ epidural / subarachnoid volume  ↑ risk

cerebral bleed, and ↓ dose neuraxial blockade required.

MAKEUP briefly describe the function of the placenta

1. The placenta is derived from foetal tissue and is the interface between maternal and foetal
circulations. Anatomically it consists of:
a. Maternal circulation – uterine a  spiral a; uterine v
b. Foetal circulation – umbilical arteries x 2, umbilical v
c. Chorionic villi – lined by syncitiotrophoblast, cytotrophoblast
d. Intervillous space – bathes the chorionic villi

2. Functions:
a. Transport
b. Immune
c. Metabolic
d. Endocrine

3. Transport:
a. Substances transported –
i. Gases: O2, CO2
ii. Nutrients
iii. Removal waste
iv. Heat
v. Others – drugs
b. Methods of transport:
i. Simple diffusion: most important and most common. This is described by
Fick’s Law and includes small lipid soluble molecules – O2, CO2, lipids,
steroids, fat soluble vitamins, drugs.
Diffusion area = 16m2, distance = 3.5µm
ii. Facilitated diffusion: requires carrier protein  glucose
iii. Active diffusion: against concentration gradient using a specific carrier
protein which uses energy. It may be saturated at high concentrations, and
competition may occur  amino acids, Ca2+, iron, iodine, water soluble
vitamins
iv. Pinocytosis: large molecules  globulins, phospholipids, lipoproteins, IgG
antibodies.

4. Immunological:
a. Protection of foetus from infection: occurs by passage of maternal IgG (pinocytosis)
into foetal circulation. The syncitiotrophoblast contains receptors for Fc portion IgG,
which permits endocytosis.
b. Tolerance from maternal immune rejection.

5. Metabolic: synthesis of glycogen, cholesterol, FFA, enzymes

6. Endocrine: 4 major hormones

a. hCG: produced in early pregnancy to maintain the corpus luteum
b. HPL:
i. similar structure to GH
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

ii. Role:
1. anti-insulin to mother  ↑GNG/glycogenolysis, ↑ fat utilisation
(catabolic)  ↑ BSL mother  ↑ glucose gradient for foetal growth
2. retains K, nitrogen
c. Oestradiol:
i. Growth, enlargement uterus
ii. Development of breast
d. Progesterone:
i. Storage of nutrients in endometrial cells  development deciduas
ii. ↓ uterine smooth muscle tone
iii. Alveoli development in breasts
iv. Secretion of nutrients from epithelium of fallopian tubes to sustain zygote
e. Minor hormones: placental corticotrophin, human chorionic somatostatin, human
chorionic thyrotropin, epidermal growth factor.
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

Physiol-07A14/90 Explain the mechanisms whereby oxygen transfer is facilitated at the placenta.

1. Oxygen is transferred from the mother to the foetus through the placenta, which acts as a gas
exchange barrier. As the uterine circulation is responsible for O2 delivery to the foetus, an
efficient gas exchange system is required.
Typical placental O2 parameters are as follows:

Parameter Uterine A Uterine V Umbilical A Umbilical V

Flow (mLs/min) 600 600 300 300
Hb (g/dL) 120 120 170 170
O2 Sats (%) 98 75 45 70
pO2 (mmHg) 100 40 18 28
pCO2 (mmHg) 32 (mother ↑MV) 45 55 40
O2 cons (mL/min) Placental = 6mL/min Foetal = 17mL/min

2. Mechanisms facilitating O2 transfer: Like the lung, O2 transfer occurs through simple passive
diffusion down a concentration gradient across the exchanging surfaces of the placenta
(chorionic villi). Factors which help this process are:
a. Placental structure suitability for gas exchange
b. ↑ affinity of HbF for O2
c. ↑ Foetal Hb concentration
d. Double Bohr effect

3. Placental structure:
a. The chorionic villus is the basic unit of the placenta and contains umbilical capillaries
surrounded by the syncitiotrophoblast and cytotrophoblast layers. The maternal
circulation comes from the uterine artery, which supplies the placenta through braches
of the spiral arteries in the decidua, which bathe the villi in the intervillous space. The
surface area of gas exchange is large (16m2) and the diffusion distance small 3.5µm. O2
can diffuse down concentration gradient efficiently according to Fick’s equation:

𝐒𝐨𝐥 𝐱 𝐀 𝐱 ∆𝐏
𝐃𝐢𝐟𝐟𝐮𝐬𝐢𝐨𝐧 =
√𝐌𝐖𝐱𝐓

b. Although this helps gas exchange, the placenta is not as efficient as the lung owing to its
↓ surface area (16  80 m2) and ↑ diffusion distance (3.5  0.5µm)

4. Affinity O2 for HbF

a. HbF has a higher affinity for O2 than HbA  HbO2 curve shifted left with p50 = 18mmHg
 ↑O2 affinity and carriage at same pO2 (80% saturated venous blood at pO2 =
30mmHg).
b. This is due to structure - 2α + 2γ units  γ (unlike β) does not bind 2,3 DPG which shifts
curve right.

5. ↑ Foetal Hb
a. Normal Foetal Hb = 170g/dL  ↑ from maternal 120g/dL  ↑ carriage O2 at ↓ partial
pressures  shifts the O2 content vs. pO2 curve upwards.

6. Double Bohr effect: describes the interaction in blood whereby Hb has ↑ affinity for O2 when
↓pCO2 (in arterial blood). And ↓ affinity O2 when ↑pCO2 as in venous blood.
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

a. Foetal circulation: umbilical artery unloads CO2 in placental  ↓ pCO2 (5540mmHg)

 ↑O2 affinity (and uptake) for blood in umbilical vein (curve shifts left)
b. Maternal circulation: uterine artery load CO2 from placenta  ↑pCO2 (3245mmHg)
 ↓O2 affinity (O2 unloading) of blood in uterine vein (curve shifts right).
c. Factors facilitating effect:
i. Double Haldane effect – the loading of O2 in blood ↓ affinity for CO2 carriage as
carbamino compounds  synergistic effect with Bohr in both maternal and
foetal circulations
ii. Maternal hyperventilation – lower pCO2 (40mmHg  32mmHg)  ↑ conc
gradient for CO2 transfer from foetus  ↑ Bohr effect
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

Physiol-02B16/99A1 Explain the Bohr and Haldane effects in trans-placental gas exchange.

1. The placenta acts as an important gas exchange organ between mother and foetus facilitating
gas transfer down concentrations gradients:
a. O2 transfer from mother  foetus
b. CO2 removal from foetus  mother

Since the placenta is functionally a much less efficient organ for gas exchange than the lung,
additional mechanism are required to facilitate adequate exchange for foetal survival.

2. Gas parameters in the placenta:

Parameter Uterine A Uterine V Umbilical A Umbilical V

Flow (mls/min) 600 600 300 300
Hb (g/dL) 120 120 170 170
O2 Sats (%) 98 75 45 70
pO2 (mmHg) 100 40 18 28
pCO2 (mmHg) 32 45 55 35
CO2 content (ml/dL) 48 52 44 37
pH 7.42 7.3 7.21 7.32
O2 cons (mL/min) Placental = 6mL/min Foetal = 17mL/min

3. Double Bohr effect: describes the interaction in blood whereby Hb has ↑ affinity for O2 when
↓pCO2 (in arterial blood). And ↓ affinity O2 when ↑pCO2 as in venous blood.
a. Circulations –
i. Foetal circulation: umbilical artery unloads CO2 in placental  ↓ pCO2
(5540mmHg)  ↑O2 affinity (and uptake) for blood in umbilical vein (curve
shifts left)
ii. Maternal circulation: uterine artery load CO2 from placenta  ↑pCO2
(3245mmHg)  ↓O2 affinity (O2 unloading) of blood in uterine vein (curve
shifts right).

Combining these features causes additional transfer of O2 from mother  placenta 

foetus.

b. Mechanism - accounts for 2-8% transplacental O2 transfer

i. ↑pCO2  ↓pH  Hb binds H+ instead of O2  ↓ O2 affinity
ii. ↑pCO2  ↑2,3 DPG binding (maternal blood)  H binds 2,3 DPG which
competes with O2  ↓O2 affinity

4. Double Haldane effect: describes the interaction in blood whereby deoxy Hb has ↑ affinity for
CO2 carriage as carbamino compounds (as in venous blood); and oxy-Hb has ↓ affinity for CO2
carriage (as in arterial blood).
a. Circulations:
i. Foetal circulation: blood from umbilical artery loads O2  ↑O2 sats (45  70%)
 ↓ affinity for CO2 carriage  CO2 unloading into placental
ii. Maternal circulation: blood from uterine artery unloads O2  ↓O2 sats (98 
75%)  ↑ affinity for CO2 carriage  CO2 loaded from placenta.
b. Mechanism: accounts for 46% transplacental CO2 transfer
i. ↑ ability of deoxy-Hb to form carbamino compounds with CO2 (70%)
ii. ↑ ability of deoxy-Hb to buffer H+ produced from CO2 + H2O  HCO3- + H+
 Dr Matthew Ho
BSc(Med) MBBS(Hons) FANZCA

Physiol-MAKEUP Briefly describe the function of amniotic fluid.

1. Amniotic fluid is fluid in the amniotic cavity which surround the foetus. It is usually 500-1500mls
and peaks 34 weeks, before declining slowly till term.

2. Formation:
a. Early: ultrafiltrate of foetal ECF
b. Later: foetal urine, which is swallowed and reabsorbed in the foetal GIT  recycling

3. Functions:
a. Cushioning the foetus which ↓ effective weight
b. Route for recycling of foetal urine output
c. Space for symmetric foetal growth and movement
d. Labour: helps evenly spread the pressure of uterine contractions.