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Epidurals and Maternal Fever
(Originally posted 15 September 1997 on About Anesthesiology)
INTRODUCTION
A recent article published in Pediatrics has brought
a great deal of attention to the issue of maternal fever and epidurals.
Specifically, concern has been raised about the number of evaluations
done in newborns for infection as a result of this finding of
fever.
It should be noted that the concept that epidurals may be associated
with maternal fever is not a completely new one and that the newest
issue raised is whether in fact the newborn is being evaluated
and treated with antibiotics at an unnecessary high rate due to
the presence of this fever.
In this article, I briefly review a few articles from the literature
related to this topic in an attempt to provide some basis and
insight into this topic.
Maternal Pyrexia Associated with the Use of Epidural Analgesia
in Labor
This first article, by Fusi, et al was published way back in
June of 1989 in Lancet (June 3, 1989: pp. 1250-1252) and
shows once again that the issue is not a new one. In this study,
forty patients with normal temperature and no evidence of infection
were evaluated. Two groups were established, one receiving only
intravenous medication for labor and the other receiving epidural
analgesia for labor.
At the beginning of labor, the groups had comparable temperatures.
The non-epidrual group maintained a normal temperature through
labor whereas the epidural group showed a significant rise after
about six hours of labor. Again, these patients did not have any
indication of infection.
Thus, the conclusion that epidurals led to fevers in these
mothers was reached. The study went on to suggest some possible
reasons for the fever - none of which really had any supporting
evidence (nor were they looking for any reasons, only the evidence
that epidurals and fever were associated).
Epidural versus Parenteral Analgesia for Labor
This second article was published in Obstetrics and Gynecology
in 1995 (vol 86: pp. 783-789) and was done to analyze the overall
obstetrical impact of the two methods of pain relief. It involved
869 patients divided between the two groups. The parenteral group
received demerol as needed and the epidural group received a continuous
infusion type of technique.
There were many variables and outcomes measured in this study
including level of relief, vaginal versus cesarean delivery, time
in labor, need for oxytocin augmentation, etc. I will not discuss
all those findings here. Of interest to us are the findings about
chorioamnionitis (defined as fever greater than 38 degrees centigrade).
Five percent of the patients receiving the demerol for pain
relief were found to have chorioamnionitis by these criteria,
whereas twenty-three percent of the patients receiving epidurals
met the criteria. The authors concluded that, despite its superior
relief of pain, epidural analgesia has several undesirable effects
on labor - one of which was the development of fever. Of interest,
no indications that either method, or the development of fever,
had any effects on neonatal outcome could be demonstrated.
Epidural Analgesia, Intrapartum Fever and Neonatal Spesis
Evaluation
This is the recent article in Pediatrics that sparked
the increased interest in this topic. It was published earlier
this year (1997, vol. 99: pp. 415-419) and received a great deal
of coverage in the popular press.
This was the first study done about maternal fever and epidurals
to make conclusions regarding the impact of this fever on clinical
practice. The study evaluated the rate of fever and the performance
of neonatal sepsis evaluations and treatment of these neonates
with antibiotics. It included 1657 women who had no fever when
admitted for labor. It looked for patients who developed temperatures
above 100.4 degrees and the relationship of this finding to neonatal
workups and treatments.
The results showed that 14.5% of women with epidurals had a
fever during labor while only 1% of patients without an epidural
developed a fever. In the absence of epidural analgesia, the fever
rate remained low no matter how long the labor was. When an epidural
was in place, the rate of fever increased as the length of labor
increased.
The neonates of mothers receiving epidurals were evaluated
for sepsis (infection) 34% of the time versus 9.8% in the other
group. These babies also were treated with antibiotics more often
(15.4% versus 3.8%). Although only 63% of the studied patients
received epidurals, these patients accounted for 96.2% of the
recorded fevers, 85.6% of the sepsis evaluations and 87.5% of
the antibiotics group.
The conclusion that epidurals are strongly related to maternal
fever, neonatal sepsis workups and neonatal treatment with antibiotics
was clear at the end of this study. The question remains, is this
a cause for concern?
I believe that it is because of the cost of workup and treatment,
the increased risk of workup and treatment, the pain to the newborn
that can be involved and the mental concern that it may cause
to the parents and the caregivers.
The study authors suggest the following steps be taken:
- Criteria currently in place for neonatal sepsis evaluation
and antibiotic treatment should be examined and perhaps altered
for babies of those mothers receiving epidurals during labor.
- There should be additional studies to see if temperature
elevations related to epidurals can be limited by different cooling
methods.
- The possible consequences of fever related to epidural usage
should be discussed with patients when making decisions about
pain relief methods to be used buring labor.
Of all of these suggestions, I believe that the third one if
the most important to our daily practice at this time.
CONCLUSIONS
There are other questions about the effects of epidural analgesia
during labor as well including whether it prolongs the first stage
of labor, whether is increases the incidence of instrument-assisted
delivery, whether it increases the incidence of cesarean section,
etc. We can add the issue of maternal fever and its effects in
the neonate to this list. The answers to each of these questions
has not been fully defined and the mechanisms for these associations
have not been clearly demonstrated.
In my opinion, clear-cut answers do not exist to these concerns.
However, I believe it is important for anesthesia providers to
be aware of the issues being raised in the literature, both the
anesthesiology literature as well as the obstetrical and pediatric
literature. It is vital that this information be provided to patients
in as clear a method as is possible to allow discussion of risks
and benefits and true informed consent to take place. Future studies
hopefully will give us better answers to these questions.
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