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Caesarean Sections. Part 1: Physiology of the Pregnant Patient


In this first instalment of a 4-part series on anaesthesia for the Caesarean section we discuss the physiological effects of pregnancy and how those changes can influence our anaesthetic choices.  Part 1 will provide the background for future instalments examining anaesthetic protocol selection, pain management, induction, maintenance, monitoring and recovery for the Caesarean section.


In the United Kingdom brachycephalic dogs are the largest breed group requiring C-sections (Moon et al., 1998) and over 80% of these are performed in Boston terriers, British bulldogs and French bulldogs (Evans & Adams, 2010).  In comparison, Robertson (2016) reported that only 8% of purebred cats required Caesarean surgery.

Emergency surgery is performed in 58% of canine C-section patients, and if parturition has been prolonged, hypovolaemia, dehydration, hypotension, exhaustion, hypothermia, hypoxia, haemorrhage, shock and toxaemia may all be present to some degree (Moon et al, 1998). In the same study Moon et al. (1998) reported a 1% mortality rate in the 808 canine C-sections studied, with 7/9 (78%) of those deaths associated with emergency procedures.  The most common causality was pneumonia, possibly as a consequence of aspiration. Additionally, the survival rate of neonates delivered to brachycephalic dams, and to dams with 4 or more foetuses was reported to be lower than those delivered to non-brachycephalic patients or those with smaller litter siszes (Moon et al., 2000).


Relative anaemia of pregnancy

During pregnancy blood volume can increase by 40%, mainly through elevations in plasma volume (Ryan & Wagner, 2006). However, maternal erythrocyte production does not match this increased plasma volume and a “dilution anaemia” or “relative anaemia of pregnancy” results. This generally develops between days 25 & 30 of the typical 63-day pregnancy, and is most severe with large litter sizes and at full-term when the haematocrit can fall to 30%-35% (Ryan & Wagner, 2006; Claude & Meyer, 2016; Robertson, 2016). The relative anaemia of pregnancy indicates significant dehydration may be present in the dam if maternal packed cell volume is normal at the time of C-section. 

Increased cardiac output

Proportional to the rise in blood volume there is an increased heart rate and stroke volume with elevations in cardiac output (CO) of 30-50% (Raffe, 2015). Despite this increased CO, blood pressure and uterine blood flow are maintained within normal limits in the healthy animal via a hormone-mediated reduction in peripheral vascular resistance with an increased capacity of blood vessels in the uterus, mammary glands, kidneys, striated muscle and cutaneous tissues (Ryan & Wagner, 2006; Kushnir & Epstein, 2012; Claude & Meyer, 2016; Robertson, 2016). 25% of cardiac output is diverted to the uterus and placenta during pregnancy (Robertson, 2016).

Baroreceptor reflex may be attenuated & myocardial contractility nears maximum

CO continues to increase throughout pregnancy until cardiac contractility reaches a maximum.  In the face of hypotension or hypovolaemia the compensatory baroreceptor mechanisms, which can be attenuated during pregnancy, may be delayed or fail. Therefore, the careful management of patients with pre-existing heart disease and reduced cardiac reserve is essential to minimise the possibility of rapid decompensation (Ryan & Wagner, 2006). 

No autoregulation of foetal blood flow. Supine recumbency may reduce cardiac output

In pregnant women supine positioning can mechanically compress the aorta and caudal vena cava resulting in decreased venous return and cardiac output with subsequent reductions in the pressure dependent perfusion of the uterus and placenta. Foetal blood flow, which is not autoregulated, also decreases (Tan & Tan, 2013). Although Probst & Webb (1983) and Probst et al (1987) did not demonstrate similar physiological changes in supine dogs, it must be assumed that supine hypotension can occur, particularly in giant breeds or dams with large litters/oversized foetuses, and steps to reduce the incidence should be taken (Robertson, 2016). (Please see Caesarean sections Parts 2, 3 & 4 for further information).

Reduced epidural & cerebrospinal spaces

During pregnancy the volumes of the epidural and cerebrospinal fluid spaces are reduced by 30-50% due to increased collateral circulation engorging the epidural veins. If epidural (extradural) anaesthesia is being considered then a smaller volume of drug will be required to achieve the same cranial extension of the block when compared to the non-pregnant animal (Schneider, 1978; Marx, 1979; Kushnir & Epstein, 2012; Claude & Meyer, 2016). (Please see Caesarean sections Parts 2 and 3 for further details)

Based on the information described above, it is essential to take steps to maintain maternal, and therefore foetal, blood pressure prior to and during elective or emergency C-sections, or any other anaesthetic procedure on a pregnant patient.


Increased metabolic rate and oxygen consumption. 

Maternal metabolic rate increases during pregnancy leading to elevations in oxygen consumption by approximately 20% (Claude & Meyer, 2016; Robertson, 2016). As a result, tidal volume and respiratory rate can potentially increase by 40% and 10% respectively (Claude & Meyer, 2016). 

Increased sensitivity of respiratory centre to carbon dioxide, reduction in ETCO2

The respiratory centre becomes more sensitive to carbon dioxide during pregnancy, and a normal maternal end-tidal carbon dioxide may be as low as 30-33mm Hg (Ryan & Wagner, 2006). 

Reduced functional residual capacity

Displacement of the diaphragm cranially by the gravid uterus reduces total lung volume, producing compression atelectasis (Kushnir & Epstein, 2012) and an approximate 20% decrease in functional residual capacity (FRC). 

Increased risk of hypoxaemia

Decreased FRC, together with a rise in metabolic rate and oxygen demand (exacerbated by stress and/or pain), increases the risk of hypoxaemia. Therefore, supplemental oxygen should be provided to the C-section patient whenever possible (Claude & Meyer, 2016; Robertson, 2016). (Please also see Caesarean sections Parts 2, 3, 4 & 5)

Maternal hypoxaemia = significant foetal hypoxaemia

Foetal haemoglobin has a greater affinity for oxygen than that of the dam, therefore small reductions in maternal haemoglobin saturation can have considerable effects on the foetus.  Maternal hypoxaemia can provoke significant foetal hypoxaemia and acidosis.  As a consequence, vasodilation in the foetal brain and myocardium, together with pulmonary, gastrointestinal, renal and skeletal vasoconstriction may occur (Ryan & Wagner, 2006).


Increased risk of regurgitation & aspiration

Elevations in circulating progesterone during pregnancy results in amplified gastric volume & acidity, and reduced gastric and lower oesophageal sphincter tone. When combined with the physical displacement of the pylorus by the gravid uterus, there is an increased risk of regurgitation, oesophagitis and aspiration during anaesthesia (Ryan & Wagner, 2006; Claude & Meyer, 2016).


Reduced BUN & creatinine

The raised blood volume and CO during pregnancy elicit increased renal blood flow and glomerular filtration, which in turn reduces serum BUN and creatinine when compared to the non-pregnant animal.  


Possible insulin resistance

During pregnancy the mammary secretion of growth hormone can produce a resistance to endogenous insulin and hyperglycaemia may occur even in the normal, healthy pregnant bitch. In gravid diabetic patients resistance to insulin therapy may be observed (Ryan & Wagner, 2006).


Reduced anaesthetic/CNS depressant drug requirements

Increased progesterone/progesterone metabolites are positive modulators of the gamma-amino-butyric acid A (GABAA) receptor, the site of action of many anaesthetic/CNS depressant drugs.  Progesterone and oestrogen also have antinociceptive activity in the pregnant patient.  Together, these changes reduce the requirement of anaesthetic and CNS depressant drugs by 25-40% when compared to non-pregnant patient (Claude & Meyer, 2016). 

To download a summary of the physiology of the pregnant patients please click here.

Article by
Dr. Karen Heskin

Originally published: Thursday, 15th April 2021
Last updated: Thursday, 1st April 2021


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

Evans K.N. & Adams V.J. (2010). Proportion of litters of purebred dogs born by caesarean section. JSAP, 51: 113-118

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

Marx C.E. (1979). Physiology of pregnancy: High risk implications. Am Soc Anesth, Pp 1251-1254

Moon P.F., Erb H.N., Ludders J.W., Gleed R.D. & Pascoe P.J. (1998). Perioperative management and mortality rates of dogs undergoing cesarean section in the United States and Canada. JAVMA, 213: 365-369

Moon P.F., Erb H.N., Ludders J.W., Gleed R.D. & Pascoe P.J. (2000). Perioperative risk factors for puppies delivered by cesarean section in the United States and Canada. JAVMA, 36: 359-368

Probst C.W. Braodstone R.V. & Evans A.T. (1987). Postural influence on systemic blood pressure in large full-term pregnant bitches during general anesthesia. Vet Surgery, 16: 471-473

Probst C.W. & Webb A.I. (1983). Postural influence on systemic blood pressure, gas exchange and acid/base status in the term-pregnant bitch during general anesthesia. Am J Vet Res, 44: 1963-1965

Raffe, M.R. (2015). Chapter 34: Anesthetic Considerations During Pregnancy and for the Newborn. In: Grimm K.A., Lamont, L.A., Tranquilli, W.J., Greene, S.A. & Robertson, S.A. (eds), Lumb & Jones Veterinary Anaesthesia and Analgesia. Wiley & Sons, Iowa, USA. pp 708-719

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

Ryan S.D. & Wagner A.E. (2006). Caesarean section in dogs: Physiology and perioperative considerations. Compendium, pp 34-43

Schnider S.M. (1978). The physiology of pregnancy. Am Soc Anesth, pp 1254-1258

Tan E.K. & Tan E.L. (2013). Alterations in physiology and anatomy during pregnancy. Best Practice & Res: Clinical Obs & Gynae, 27: 791-802

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Capnography – Not Just a Load of Hot Air

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

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Perspectives on Premeds – Alpha-2 Agonists

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

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Alfaxan - now licensed for use in pet rabbits

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

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