Maternal Epidural Anesthesia is Associated with Sepsis Evaluation in the Newborn
ABSTRACT & COMMENTARY
Synopsis: Maternal epidural analgesia during labor is associated with intrapartum fever and also with evaluation of the neonate for possible sepsis and empiric antibiotic treatment. Maternal fever, as an isolated finding following epidural analgesia, may not be a significant risk factor for neonatal sepsis.
Source: Lieberman E, et al. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics 1997;99:415-419.
In a recent study, lieberman et al prospectively evaluated 1657 nulliparous women with term pregnancies for the association of epidural analgesia during labor with maternal intrapartum fever (temperature > 100.4°F [38°C]), neonatal sepsis evaluation, and neonatal antibiotic treatment. Intrapartum fever occurred in 14.5% of women receiving epidural analgesia but in only 1.0% of women not receiving an epidural. Without epidural analgesia, the rate of fever was low regardless of the duration of labor. With epidural analgesia, the rate of fever increased from 7% for labors of six hours or less to 36% for labors greater than 18 hours. Neonates whose mothers received epidurals were more often evaluated for sepsis (34.0% vs 9.8%) and were more often treated empirically with antibiotics for sepsis (15.4% vs 3.8%).
COMMENT BY HAL B. JENSON, MD, FAAP
Perhaps no other aspect of pediatric medicine is as vexatious, and sometimes controversial, as the management of fever in neonates and young infants. All of us recognize the low likelihood of neonatal sepsis for a single patient, yet we readily initiate evaluation and empiric antibiotic treatment for subtle signs that are suggestive of sepsis, including intrapartum fever in the mother. This traditional approach acknowledges the difficulty of early diagnosis and the potentially disastrous outcome with delayed diagnosis and initiation of therapy.
Several reports in the past few years have documented the association of maternal intrapartum fever following epidural analgesia.1,2 Approximately 61% of women with intrapartum fever have received epidural analgesia compared to only approximately 21% of women with normal temperatures.3 This new report documents that epidural analgesia not only affects the mother but also has consequences for the medical management of the infant. Neonatal sepsis was more often suspected in infants born to mothers receiving epidural analgesia, resulting in more frequent evaluations for sepsis and more frequent empiric antibiotic treatment. Most neonates of mothers with intrapartum maternal fever of greater than 100.4°F were evaluated for fever regardless of history of epidural analgesia. The 63% of women who received epidurals accounted for 96.2% of mothers with fever, 85.6% of neonates evaluated for sepsis, and 87.5% of neonates treated with antibiotics for possible sepsis. Multiple logistic regression analysis (adjusting for birth weight, gestational age, induction of labor, premature rupture of membranes, and treatment with active management of labor) of mothers with no intrapartum fever showed that newborns of mothers who received an epidural were more than three times as likely to be evaluated for sepsis.
Evaluation of possible neonatal sepsis requires a comprehensive approach; assessment of maternal risk factors is a component of that evaluation. Epidural analgesia should be included as one risk factor associated with maternal fever, which itself is only one risk factor associated with neonatal infection. Communication with the obstetrician and assessment for other causes of maternal fever remain essential. Maternal fever as an isolated finding following epidural analgesia may not be a significant risk factor for neonatal sepsis. The decision for laboratory evaluation of a newborn for sepsis and empiric treatment should still be based on the physician’s clinical judgment of all risk factors, physical examination findings, and results of appropriate laboratory tests. The association of epidural analgesia with maternal intrapartum fever and now with neonatal sepsis evaluation will be reassuring post facto in the management of the well-appearing neonate born to a mother who had epidural analgesia and who is suspected to have sepsis primarily on the basis of maternal fever.
References
1. Fusi L, et al. Maternal pyrexia associated with the use of epidural analgesia in labor. Lancet 1989;1:1250-1252.
2. Vinson DC, et al. Association between epidural analgesia during labor and fever. J Fam Practice 1993;36:617-622.
3. Herbst A, et al. Risk factors for fever in labor. Obstet Gynecol 1995;86:790-794.
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