--- module: 054-02 language: en chapter: 54 title: "Antenatal Care, Pregnancy Complications, Labour, and the Puerperium" module_title: "Maternal adaptation, placental physiology, obstetric emergencies, and postpartum transition" source_sha256: c5de16d17fdd591d666dfbccdc7f2a5756880dd20649dc7d24a34042c510381a --- # Maternal adaptation, placenta, emergencies, postpartum ## Adaptation and maternal resuscitation ### Adaptations mimic disease #### Non-pregnant normal creatinine may mean impairment #### Modest bleeding turns dangerous as compensation fails ### Maternal resuscitation is fetal resuscitation #### Left uterine displacement eases aortocaval compression #### Compressions and defibrillation not delayed #### Early preparation for emergency delivery ### Search causes in parallel, keep resuscitating ## Organ system adaptation ### Dilutional anaemia despite rising red-cell mass ### Supine vena cava compression, relieved laterally ### Progesterone drives ventilation #### Non-pregnant normal carbon dioxide: hypoventilation ### Functional residual capacity falls #### Little oxygen reserve during apnoea ### Filtration up lowers urea and creatinine #### Glycosuria does not diagnose diabetes ### Hypercoagulability #### Protects against delivery bleeding #### Raises venous thrombosis, especially postpartum ## Placental physiology ### Exchange and endocrine organ ### Spiral arteries remodel to low resistance #### Failed remodelling causes placental ischaemia #### Antiangiogenic signals injure endothelium #### Pre-eclampsia, growth restriction, abruption ### High maternal pressure, poor placental flow ## Early pregnancy ### Positive gonadotropin: activity, not location ### Discriminatory thresholds are not absolute ### Ectopic rupture at low or falling levels #### Shoulder-tip pain, syncope, shock: surgery ### Hyperemesis: exclude multiple and molar pregnancy ### Vomiting depletes thiamine #### Carbohydrate first risks Wernicke encephalopathy ## Pre-eclampsia, HELLP, and eclampsia ### Multisystem placental endothelial disease #### Diagnosable without proteinuria ### Warnings: headache, vision, epigastric pain, reflexes ### Severe hypertension treated urgently #### Prevents maternal intracranial haemorrhage ### Magnesium sulphate for eclamptic seizure #### Monitor reflexes, breathing, urine; calcium antidote ### Cautious fluid: leak risks pulmonary oedema ### Delivery removes placenta, timing balanced ### HELLP: haemolysis, liver enzymes, low platelets ### Eclampsia before, during, or after birth ### Lifelong cardiovascular risk ## Gestational diabetes ### Insulin resistance exceeds beta-cell reserve ### Maternal glucose drives fetal insulin #### Growth and fat deposition #### Neonatal hypoglycaemia after birth ### Insulin need falls after placental delivery ### Postpartum testing for persistent diabetes ## Antepartum bleeding and fetal surveillance ### Praevia: painless bleeding, no digital exam ### Abruption: painful bleeding, may be concealed ### Vasa praevia: fetal bleeding at membrane rupture ### Growth restriction versus constitutionally small #### Redistribution to brain and heart #### Serial rather than single measurements ## Labour and intrapartum emergencies ### Fetal heart monitoring is indirect #### Autonomic response, not an oxygen meter ### Shoulder dystocia: head traction injures plexus #### Suprapubic pressure, internal rotation, posterior arm ### Cord prolapse: elevate presenting part ### Uterine rupture: bradycardia, loss of station ## Postpartum haemorrhage ### Tone, tissue, trauma, thrombin ### Atony: massage, empty bladder, uterotonics ### Visual estimates underestimate loss ### Activate protocol on physiology, not numbers ### Fibrinogen falls early #### Higher pregnancy range: mild fall can be severe ## Postpartum transition ### Autotransfusion can expose heart failure ### Endometritis: fever, tenderness, offensive lochia ### Sepsis: fever may be absent #### Trend and organ function carry more weight ### Lactation: assess transfer, not motivation ### Medicines: no blanket stop to feeding ### Mental illness from blues to psychosis #### Explicit risk assessment for intrusive thoughts ### Discharge: separate safety plans ### Transfer records for lifelong prevention