Background Previous small studies have shown an association between epidural analgesia and intrapartum fever. This study used a much larger sample to investigate the impact of epidural analgesia on maternal fever, neonatal sepsis evaluation, and antibiotic treatment of newborns.
Population studied Data were abstracted from the 1934 nulliparous women enrolled in the Active Management of Labor (ACT) trial. The ACT trial was designed to study whether active management of labor could lower cesarean section rates. Women at 30 weeks' gestation who were at an increased risk of cesarean section were excluded. The study was further limited to singleton, term, nondiabetic, cephalic-presenting pregnancies in women who were admitted without fever or infection and whose labor resulted in a liveborn infant. The final sample of 1657 was mostly white (76%) and privately insured (96%). Of these, 63% received epidural analgesia on request. Women receiving epidural analgesia were more likely to have induced rather than spontaneous onset of labor (28% of epidural users vs 12% without epidurals) and, on average, their labors were almost 6 hours longer.
Study design and validity This study is a retrospective analysis of data from the ACT trial as it relates to epidural use, neonatal sepsis workups, and antibiotics. The case-control design makes causal determination difficult because of the potential for bias. The relationship between epidural use and maternal fever, neonatal sepsis evaluation, and treatment with antibiotics was examined while controlling for birthweight, gestational age, induction of labor, premature rupture of membranes, and treatment with active management of labor.
The investigators did not control for duration of rupture of membranes; number of maternal vaginal examinations; intrapartum antibiotic prophylaxis and its effect on neonatal evaluation; neonatal Apgar scores, or resuscitation needs. Although the investigators controlled for duration of labor in calculating the relationship between epidural analgesia and neonatal sepsis evaluation, they did not do so with regard to maternal fever or neonatal treatment with antibiotics. The relationship between epidural analgesia and maternal fever may thus be confounded by dystocia producing longer labor, resulting in more requests for epidural analgesia, and an increased likelihood of fever and neonatal problems.
Outcomes measured The primary outcomes measured were the adjusted odds ratios (likelihood) of maternal fever, neonatal sepsis evaluation, and treatment with antibiotics in women given epidural analgesia compared with those not given it.
Results Intrapartum fever >100.4[degrees]F (38[degrees]C) occurred in 14.5% of women receiving epidural analgesia, compared with 1 % of those who did not. The adjusted odds ratio for the association between epidural analgesia and maternal fever was 14.5 (95% Cl, 6.3 to 33.2); 2.1 (95% CI, 1.4 to 2.9) for the relationship to neonatal sepsis evaluation; and 3.9 (95% CI, 2.1 to 6.1) for the association with neonatal antibiotic treatment. For labors less than 6 hours, the difference in the rate of fever between the epidural and no-epidural group was relatively small (7% vs 1%). As the duration of labor increased above 6 hours, the incidence of fever increased to 36% in the epidural group, while remaining low in the no-epidural group. Of the total 416 infants evaluated for sepsis, only 4 had documented sepsis.
Recommendations for clinical practice Women who chose epidural analgesia in this study had a markedly increased risk of intrapartum fever; likewise, their newborns were more likely to require a sepsis workup and antibiotic treatment. It remains uncertain whether epidural analgesia causes maternal fever or is just a risk marker. Nevertheless, based on the strong association found in this study, family physicians providing obstetrical care should discuss with patients considering epidural analgesia the possible increased risk of fever, sepsis evaluation, and antibiotic treatment of their neonates, in addition to the increased risk of operative delivery.(1)
REFERENCE
(1.) Robbins CW, Slawson DC. Epidural analgesia in labor. J Fam Pract 1996; 42:227-8.
COPYRIGHT 1997 Dowden Health Media, Inc.
COPYRIGHT 2004 Gale Group
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