Epidural Analgesia and Fever
Khalid N. Haque, FRCP (Lond), FRCP (Edin), FRCP (Ire), FRCPCH, FPAMS, FICP, MBA, DCH (Lond), DTM&H (Liv)Patrick Radford, MBBS, FRCA
St Helier Hospital
Wrythe Lane
Carshalton, Surrey SM5 1AA England
To the Editor.—
We read the article by Goetzl et al1 with interest. While we agree that there is an association between epidural analgesia and increased maternal temperature,2 we would question that epidural analgesia in the mother per se leads to increased screening for sepsis in the newborn whether the mother is febrile or afebrile after an epidural.
At St Helier Hospital we have reviewed 461 consequent deliveries. In this audit we noted the following irrespective of whether the mothers received epidural analgesia or not: parity, mode of delivery, time from membrane rupture to birth, duration of first and second stage, maternal temperature on arrival in the delivery suite, maternal temperature during labor, if there was any other reason (eg, infection) to explain maternal pyrexia, infant’s temperature immediately after birth, if the infant received a sepsis screen, if the infant was prescribed antibiotics, and if the infant developed within the first 7 days after birth.
At our institution women are also given the choice to choose epidural analgesia. Midwives and obstetricians may also recommend this option for a labor that seems more painful than normal or has an increased risk of surgical delivery or in the presence of certain medical disorders, such as preeclampsia. If they choose epidural analgesia they are given bupivacaine 0.1% with fentanyl 2 µg/mL. Drugs are not prewarmed and are administered either by an anesthetist or a midwife as boluses as required. We defined increased maternal temperature as a core temperature of >38°C. Neonatal sepsis screen, which includes a blood culture; complete blood count; and C-reactive protein (lumbar puncture is included on the basis of clinical suspicion), is performed routinely if the infant is <35 weeks’ gestation, membranes had been ruptured for 72 hours or longer in a term infant,3 if the membranes have been ruptured for 24 hours or more in preterm deliveries, if there is evidence of maternal chorioamnionitis, respiratory distress in the infant apnea, sustained tachycardia (>160 bpm) or other nonspecific symptoms like temperature instability and lethargy in the infants.
Of the 461 women we could not find the details of 3 thus the analysis is based on 458 deliveries. Four hundred fourteen women delivered vaginally while 44 (10.6%) required cesarean section. One hundred sixty-three (35.5%) received epidural analgesia. The epidural rate for nulliparous women was 54% (93 out of 172) and for multiparous 24% (70 out of 286). Both parity and epidural analgesia were significantly associated with cesarean delivery. The rates were 13% for nulliparous and 7% for multiparous women. The rate of cesarean section for women choosing epidural analgesia was 18%, whereas the rate for those using other techniques, excluding epidural analgesia, was only 5%. Maternal hyperthermia (>38°C) was documented in 2.5% of mothers who chose epidural analgesia compared with only 0.3% in mothers who did not receive epidural analgesia.
While the overall rate for sepsis screening in the newborn in our hospital was 4%, none of the infants born to mothers who received epidural analgesia required screening for sepsis irrespective whether the mother was afebrile or febrile.
While we did find increased maternal temperature after epidural analgesia (2.5% compared with 0.3%), we found no evidence that epidural analgesia increased the proportion of newborn infants warranting a sepsis screen or antibiotic therapy. Obviously, there are differences in both obstetric and neonatal practices between the 2 institutions but we find it difficult to understand the high rates of both increased maternal temperature and the frequency of sepsis screening in the newborn after epidural analgesia. This is particularly concerning when "fewer than 50% of infants evaluated received antibiotic therapy." We note that the authors are planning to look at their policy for sepsis screening but we are also caution against withholding antibiotics from an infant at risk of infection, presumably until culture results are available. At our institution if we perform a sepsis screen in a newborn infant we mandate the initiation of antibiotic therapy until the blood culture results are known.
We feel that epidural analgesia is an efficient and effective means of pain relief for women in labor and it does not lead to an increased need for screening for sepsis or antibiotic therapy in their infants.
REFERENCES
- Goetzl L, Cohen A, Frigoletto F Jr, Ringer SA, Lang JM, Lieberman E. Maternal epidural use and neonatal sepsis evaluation in afebrile mothers.
Pediatrics.2001; 108
:1099
–1102
[Abstract/Free Full Text] - Philip J, Alexander JM, Sharma SK, Leveno KJ, McIntire DD, Wiley J. Epidural analgesia during labour and maternal fever. Anesthesiology.1999; 90 :1270 –1275
- Haque KN. Management of babies born after prolonged rupture of membranes. Postgrad. Doct.1993; 16 :342 –347
Laura Goetzl, MD, MPH
Ellice Lieberman, MD, DrPH
Amy Cohen, BS
Fredric Frigoletto, Jr, MD
Department of Obstetrics and Gynecology
Baylor College of Medicine
Houston, TX
Department of Obstetrics and Gynecology
Brigham and Women’s Hospital
Boston, MA
Massachusetts General Hospital
Boston, MA
In Reply.—
We appreciate the interest of Drs Haque and Radford in our work. There are a number of reasons why the findings in their data may differ from those we report. Our population was limited to low-risk, term, nulliparous women. In contrast, Drs Haque and Radford apparently included all deliveries, including nulliparas and multiparas, as well as women with preterm deliveries and women who were high-risk because of the presence of medical conditions. Because these factors are likely to influence the relative frequencies of epidural use, intrapartum fever, and sepsis evaluation, their inclusion of all women may explain some of the differences in our findings. For example, the inclusion of multiparous women is likely to be at least part of the explanation for the very low rate of fever they report with epidural when compared with other studies that have examined this issue.1,2
However, even given these differences in population, we are confused by the findings reported by Drs. Haque and Randford. In their cohort, in which more than one third of women received epidural analgesia, no infants of women who received epidural required a sepsis evaluation, despite a significantly higher rate of fever in that group. We find the absence of sepsis evaluations in this group surprising because Drs Haque and Randford also indicate that maternal chorioamnionitis, which is usually diagnosed based on intrapartum fever, was an indication for neonatal sepsis evaluation at their institution. Although the rate of sepsis evaluation will vary across institutions based on specific criteria chosen, it seems logical to us that any institution where maternal fever prompts a neonatal sepsis evaluation should have a higher rate of evaluation in the infants of epidural users on that basis alone. A higher rate of sepsis evaluation with epidural has been reported in 2 studies,1,2 one of which was a randomized trial.2
We agree that withholding antibiotics from symptomatic infants is unwise. However, at institutions where risk factors are used to identify asymptomatic infants for evaluation, it is less clear that antibiotic treatment is always needed. Additional research is needed to refine the indications for neonatal sepsis evaluation and antibiotic treatment among asymptomatic infants.
However, until it is possible to distinguish infectious from noninfectious fever during labor, fever in a mother with epidural analgesia cannot be ignored by pediatricians.
REFERENCES
- Lieberman E, Lang JM, Frigoletto F Jr, Richardson DK, Ringer SA, Cohen A. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation.
Pediatrics.1997; 99
:415
–419
[Abstract/Free Full Text] - Philip J, Alexander JM, Sharma SK, Leveno KJ, McIntire DD, Wiley J. Epidural analgesia during labor and maternal fever. Anesthesiology1999; 90 :1271 –1275[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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