One of the topics that I was asked about at one of the recent ‘Recipes for Normal Birth’ workshops was that of ‘epidural fever’ and, as promised, here’s a post linking to my article on this topic along with three recent studies on this…
Epidural fever is the colloquial term used to describe a side effect thought to be associated with epidural analgesia: an increase in the maternal and neonatal temperature and pulse. We have known about this possible side effect for at least a couple of decades, and there’s no easy answer to the problem it causes, wherein lots of women and babies end up with unnecessary testing (known in some areas as a septic work-up) and/or antibiotics as a result of having epidurals.
Having a raised temperature and pulse is also a sign of infection, and infection in childbearing women and babies is not something to take lightly. We can’t dismiss a raised temperature in a woman or baby who have been exposed to epidural analgesia just because it’s a known side effect, because a proportion of those women and babies will actually have an infection. But, as I first wrote some time back in an article called Epidural Fever, “surely we need to find some way of ensuring that women who have epidurals are not automatically signing themselves and their babies up for antibiotics, longer hospital stays and the potential impact these things may have on their first days together.”
One of my suggestions in that article was for us to think a bit laterally about how infection manifests.
“I have rarely seen a baby with an infection whose only symptom was pyrexia; generally they tend to show one or more other symptoms, such as breathing anomalies, being unresponsive, floppy or jittery, not feeding well or seeming generally unsettled.” (Wickham 2002: 21)
That’s just my experience though, and maybe yours is different?
Agakidis et al (2011) undertook a retrospective observational study of 480 babies and showed that epidural analgesia was an independent risk factor for neonatal pyrexia even after controlling for intrapartum pyrexia and other potentially confounding factors. In their study, babies born to women who had epidurals were five times more likely to have a sepsis work-up than babies born to women who did not have epidurals. They concluded that “epidural analgesia in labor is an independent risk factor for pyrexia in term neonates. It is unnecessary to investigate febrile offspring of mothers who have had epidurals unless pyrexia persists for longer than 5h or other signs or risk factors for neonatal sepsis are present.”
Heesen at al (2012) published a review of five studies (including two RCTs and three observational studies) reporting the outcomes of 4667 women, concluding that “Our data suggest that EDA-related maternal hyperthermia results in an increased likelihood of sepsis workup and antibiotic treatment of the infant. A crucial question is whether EDA-related maternal hyperthermia is truly infectious. If not, administration of antibiotics would not be justified and may be dangerous.”
A 2013 review of this topic by Arendt and Segal showed that this area was not quite as straightforward as we originally thought. While they did not go so far as to refute this association, they describe it as complex and controversial, and highlight a number of concerns with some of the studies, including the suggestion that women who have longer labours are more likely to get an infection (and therefore a fever) and are more likely to request an epidural. They also point out that the studies of this area have tended to compare women who had epidurals to women who had opiod or other analgesia, and it is well understood that some (non-epidural) analgesics have an antipyretic (temperature-reducing) effect. As Arendt and Segal (2013) suggest, we really need to compare women who had epidurals to women who were unmedicated. They conclude that, “With the current popularity of epidural analgesia in labor, it is important that clinicians delineate how epidurals cause maternal fever and how to block the noninfectious inflammatory response that seems to warm a subset of women laboring with epidurals.”
Agakidis C, Agakidou E, Thomas SP et al (2011). Labor epidural analgesia is independent risk factor for neonatal pyrexia. Journal of Maternal-Fetal and Neonatal Medicine 24(9):1128-1132.
Arendt KW and Segal BS (2013). The association between epidural labor analgesia and maternal fever. Clinics in Perinatology 40(3): 385-98.
Heesen M, Klohr S, Rossaint R et al (2012). Labour epidural analgesia and anti-infectious management of the neonate: a meta-analysis. Journal of Perinatal Medicine 40(6): 625-630.