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Intrapartum Maternal Fever
Intrapartum Maternal Fever and Neonatal Outcome. Lieberman E, Lang J, Richardson DK, et al. Pediatrics (2000); 105:8-13.
Much of maternal fever during labor may not be infectious, but rather a consequence of epidural anesthesia. The authors investigated the association between elevated maternal intrapartum temperature and neonatal outcome when the infant does not develop an infection.
The study included 1218 nulliparous women with singleton term pregnancies in a
vertex presentation and spontaneous labor. Women were excluded if their temperature was >99.5 at admission for delivery, if they were diabetic or had an active genital herpes infection, or if their infant developed a neonatal infection, had a congenital infection, or had a major malformation. During labor, 123 women (10.1%) developed fever >100.4, 62 (5.1%) had a maximum temperature of 100.5 to 101, and 61 (5.0%) had a maximum temperature >101. Of febrile women, 97.6% had received epidural anesthesia (versus 55.2% of afebrile women). Infants of women developing fever >100.4 were more likely to have a 1-minute Apgar score <7 (22.8% vs 8% for afebrile women), and to be hypotonic after delivery (4.8% vs 0.5% for afebrile women). Compared with infants of afebrile women, infants whose mothers’ maximum temperature was >101 were more likely to require bag and mask ventilation (11.5% vs 3.0%), and to be given oxygen therapy in the nursery (8.2% vs 1.3%). They also found a higher incidence of neonatal seizures with fever (3.3% vs 0.2%), but the number of infants with seizures was small (n=4).
Comment. This study has several limitations. It is unclear whether the neonatal problems seen in infants born to febrile mothers were due to the hyperthermia or to the cause of the fever (possibly epidural anesthesia) or possibly just independently associated (ie the sun rises when the rooster crows). It is also possible that the lower Apgar scores or need for resuscitation might be because pediatricians or neonatologists are more frequently present in the delivery room when maternal fever occurs. Pediatric physicians may assign Apgar scores differently than nurses, and they may have a lower threshold for using bag and mask ventilation. This would not explain the higher incidence of hypotonia or seizures in these patients however.
Most of the adverse neonatal effects noted in this study were transient. The Apgar scores were better by 5 minutes (though still lower than those of infants born to afebrile women). Hypotonia was resolved by the time of discharge in all but one infant (born to an afebrile mother). A finding that seems more clinically significant was the higher proportion of infants born to febrile women who had more serious depression at birth (1-minute Apgar <5). This finding was present in 10% of babies born to women with maximum temperatures >101 vs 2.8% of babies born to afebrile women. In light of this finding, it would seem prudent to have a pediatric physician available at delivery whenever maternal fever during labor is present.
Andrew B. Kairalla MD