Intrapartum fever, epidural analgesia and histologic chorioamnionitis

Impact and Contributing Factors of Maternal Pyrexia Peaks During Labor on Maternal and Neonatal Outcomes

This study aims to equip clinicians with the necessary insights for identifying and managing pregnant women experiencing elevated maternal pyrexia during labor. It examines maternal and neonatal outcomes along with the factors associated with varying peak temperatures. A retrospective analysis was conducted on 319 pregnant women presenting with maternal pyrexia during labor. Participants were categorized into two groups based on peak temperature: Group A (n = 180, temperature <38°C) and Group B (n = 139, temperature ≥38°C). Basic characteristics, blood markers, and maternal and neonatal outcomes were compared between the two groups. (1) Group B exhibited a higher percentage of neutrophilic granulocytes (NE%) and C-reactive protein to lymphocyte ratio (CLR) compared with Group A (p < 0.05). (2) The rates of meconium-stained amniotic fluid, histological chorioamnionitis, hospitalization of neonates, and infections in neonates were greater in Group B than in Group A (p < 0.05). (3) Logistic regression analysis identified elevated CLR levels as a risk factor for peak temperatures exceeding 38°C, indicating that CLR could serve as a reliable predictor of maternal pyrexia above 38°C during labor. Higher maternal pyrexia peaks may exacerbate adverse maternal and neonatal outcomes, emphasizing the importance of timely clinical intervention. NE% and CLR could serve as valuable indicators for identifying underlying causes and predicting peak maternal pyrexia during labor.

Characteristics and Management of Chorioamnionitis at an Academic Centre in Ontario Before and After Implementation of an Order Set

OBJECTIVES

Chorioamnionitis has implications for parturient and neonatal outcomes but is difficult to diagnose accurately. The particulars of management also differ between providers and between institutions. Clinical order sets have been shown to standardize and improve care. This study compares characteristics of chorioamnionitis and aspects of management before and after implementation of an order set.

METHODS

Chart review facilitated comparison of 76 cases occurring prior to implementation of the order set and 66 cases occurring after. Characteristics of chorioamnionitis used for diagnosis and particulars of management were assessed.

RESULTS

There was no significant difference in baseline characteristics between the groups. Parturient tachycardia was more prevalent in cases occurring after implementation of the order set but there was no difference in the percentage of cases meeting Gibb's criteria. Management of cases pre- and post-implementation of the order set differed only in antibiotic choice. Percentage of cases with blood cultures or placental examination performed did not differ.

CONCLUSIONS

Overall, implementation of the order set did not significantly impact diagnosis of chorioamnionitis and altered management only with respect to antibiotic choice.

Maternal intrapartum fever during epidural labour analgesia: Incidence and influencing factors

BACKGROUND

The management and nursing care of women's temperature during delivery is an important part of clinical obstetrics. We aimed to evaluate maternal intrapartum fever during epidural labour analgesia to provide evidence for the management and care of women in labour.

METHODS

This study was conducted and reported according to the STROBE statement. Women in labour undergoing epidural labour analgesia in our hospital from 1 January 2021 to 31 August 2022 were retrospectively selected. The characteristics of women in labour with and without intrapartum fever were compared. Pearson correlation and logistic regression analysis were used to analyse the influencing factors of postpartum fever.

RESULTS

A total of 196 women in labour were included, the incidence of maternal intrapartum fever in women in labour undergoing epidural analgesia was 27.5%. Pearson correlation analyses showed that BMI, oxytocin use, labour duration, number of vaginal examinations, time from rupture of the foetal membranes to the end of labour and duration of epidural analgesia were all correlated with the occurrence of intrapartum fever (all P < 0.05). Logistic regression analyses indicated that body mass index ≥28 kg/m2 (OR = 1.825), oxytocin use (OR = 2.082), labour duration ≥9.2 h (OR = 2.613), number of vaginal examinations ≥8 (OR = 2.044-3.115), the time from rupture of the foetal membranes to the end of labour ≥250 min (OR = 2.766) and duration of epidural analgesia ≥300 min (OR = 3.106) were risk factors for intrapartum fever in women in labour undergoing epidural analgesia (all P < 0.05).

CONCLUSIONS

Maternal intrapartum fever in women in labour undergoing epidural analgesia is common and influenced by many factors. Nurses should take early preventive care measures according to these factors during epidural analgesia in labour.

Epidural-related maternal fever: incidence, pathophysiology, outcomes, and management

Epidural-related maternal fever affects 15% to 25% of patients who receive a labor epidural. Two meta-analyses demonstrated that epidural-related maternal fever is a clinical phenomenon, which is unlikely to be caused by selection bias. All commonly used neuraxial techniques, local anesthetics with or without opioids, and maintenance regimens are associated with epidural-related maternal fever, however, the impact of each component is unknown. Two major theories surrounding epidural-related maternal fever development have been proposed. First, labor epidural analgesia may lead to the development of hyperthermia through a sterile (noninfectious) inflammatory process. This process may involve reduced activation of caspase-1 (a protease involved in cell apoptosis and activation of proinflammatory pathways) secondary to bupivacaine, which impairs the release of the antipyrogenic cytokine, interleukin-1-receptor antagonist, from circulating leucocytes. Detailed mechanistic processes of epidural-related maternal fever remain to be determined. Second, thermoregulatory mechanisms secondary to neuraxial blockade have been proposed, which may also contribute to epidural-related maternal fever development. Currently, there is no prophylactic strategy that can safely prevent epidural-related maternal fever from occurring nor can it easily be distinguished clinically from other causes of intrapartum fever, such as chorioamnionitis. Because intrapartum fever (of any etiology) is associated with adverse outcomes for both the mother and baby, it is important that all parturients who develop intrapartum fever are investigated and treated appropriately, irrespective of labor epidural utilization. Institution of treatment with appropriate antimicrobial therapy is recommended if an infectious cause of fever is suspected. There is currently insufficient evidence to warrant a change in recommendations regarding provision of labor epidural analgesia and the benefits of good quality labor analgesia must continue to be reiterated to expectant mothers.

[Sepsis during pregnancy: Key points in 2022]

Sepsis is a severe affection, that requires an urgent and specific treatment sequence. Physiological changes occurring during pregnancy make the diagnosis of sepsis more challenging in this setting, with possible delay in treatment initiation, that in turn is responsible for poorer maternal and fetal outcome. This review aims to summarize current knowledge on the diagnosis and treatment of maternal sepsis, as well as persistent knowledge gaps in the field.

The effects of combined spinal-epidural analgesia and epidural anesthesia on maternal intrapartum temperature: a randomized controlled trial

Background

Labor epidural analgesia has been suggested to be associated with intrapartum fever. We designed this study to investigate the effects of epidural analgesia and combined spinal-epidural analgesia on maternal intrapartum temperature.

Methods

Four hundred healthy nullipara patients were randomly assigned to receive either epidural analgesia (EA group) or combined spinal-epidural analgesia (CSEA group). Maternal temperature was measured hourly after analgesia administration. The primary outcome was the incidence of maternal fever, and the secondary outcomes were the duration of analgesia, analgesia to full cervical dilation and analgesia to delivery. Neonatal outcomes and other basic labor events were also recorded.

Results

Maternal temperature gradually increased with time in both analgesia groups during labor. However, the CSEA group had a lower incidence of maternal fever, and a lower mean maternal temperature at 5 h, 6 h, and 9 h after analgesia. In addtion, the CSEA group also had a shorter time of analgesia duration, analgesia to full cervical dilation, analgesia to delivery, and less dose of epidural local anesthetic than the EA group.

Conclusion

Our findings suggest that combined spinal-epidural analgesia is associated with a lower risk of intrapartum fever than epidural analgesia.

Trial registration

ChiCTR1900026606. Registered on 16/10/2019.

Screening and diagnosis of women for chorioamnionitis: An integrative literature review

OBJECTIVE

This integrative literature review provides an overview of current best research evidence on the screening and diagnosis of women for chorioamnionitis, as no current review has been conducted. An overview of best practices on screening and diagnosis of women for chorioamnionitis can assist midwives with an accurate diagnosis, allowing for early referral and adequate management of this infection.

DESIGN

An integrative literature review was conducted using a systematic electronic literature search through EBSCOhost (CINAHL with Full Text, e-Book Collection, Health Source: Nursing/Academic Edition, MEDLINE, Open Dissertations and PsycINFO), Cochrane Online, PubMed, Scopus, followed by a manual search for grey literature using Google and a citation search. Guidelines, research studies, and reports in English related to chorioamnionitis from 2008 up until 2020 were included in the study.

FINDINGS

After critical appraisal, using the Joanna Briggs Institution's checklists, Evaluation Tool for Quantitative Research Studies' tool and the Appraisal of Guidelines for Research & Evaluation instrument, 31 articles were included. More than half (64%) of the literature included ranked on the three highest levels of evidence (Level I, II and III). Data extracted regarding screening and diagnosis of women for chorioamnionitis was synthesised into four themes, namely: screening by clinical signs and symptoms, screening by causative factors of chorioamnionitis, screening of obstetric history, and essential biomarkers to diagnose chorioamnionitis.

KEY CONCLUSIONS

Screening and recording of any risk factors will assist midwives in providing tailored health education to possibly prevent causative factors that could lead to chorioamnionitis. Although matrix-metalloproteinase-8 (MMP-8) seems the most suitable test to use for screening, an accurate diagnosis of chorioamnionitis requires a combination of screening methods and tests, such as clinical signs and symptoms, maternal biomarkers, amniotic fluid testing and histology. Screening for chorioamnionitis, particularly the parameters for maternal fever as a clinical symptom of chorioamnionitis, contributing factors and microbes responsible for chorioamnionitis, the usability of MMP-8 and the development of rapid, inexpensive, easy-to-use techniques for screening and diagnosis of chorioamnionitis, warrants further research.

IMPLICATIONS FOR PRACTICE

Findings can be used by midwives in the screening and diagnosis of women for chorioamnionitis which allows for early referral and adequate management before maternal and neonatal complications arise.

Severity of intrapartum fever and neonatal outcomes

BACKGROUND

The few studies that have addressed the relationship between severity of intrapartum fever and neonatal and maternal morbidity have had mixed results. The impact of the duration between reaching maximum intrapartum temperature and delivery on neonatal outcomes remains unknown.

OBJECTIVE

To test the association of severity of intrapartum fever and duration from reaching maximum temperature to delivery with neonatal and maternal morbidity.

STUDY DESIGN

This was a secondary analysis of a prospective cohort of term, singleton patients admitted for induction of labor or spontaneous labor who had intrapartum fever (≥38°C). Patients were divided into 3 groups according to maximum temperature during labor: afebrile (<38°C), mild fever (38°C-39°C), and severe fever (>39°C). The primary outcome was composite neonatal morbidity (umbilical artery pH <7.1, mechanical ventilation, respiratory distress, meconium aspiration with pulmonary hypertension, hypoglycemia, neonatal intensive care unit admission, and Apgar <7 at 5 minutes). Secondary outcomes were composite neonatal neurologic morbidity (hypoxic-ischemic encephalopathy, hypothermia treatment, and seizures) and composite maternal morbidity (postpartum hemorrhage, endometritis, and maternal packed red blood cell transfusion). Outcomes were compared between the maximum temperature groups using multivariable logistic regression. Cox proportional-hazards regression modeling accounted for the duration between reaching maximum intrapartum temperature and delivery.

RESULTS

Of the 8132 patients included, 278 (3.4%) had a mild fever and 74 (0.9%) had a severe fever. The incidence of composite neonatal morbidity increased with intrapartum fever severity (afebrile 5.4% vs mild 18.0% vs severe 29.7%; P<.01). After adjusting for confounders, there were increased odds of composite neonatal morbidity with severe fever compared with mild fever (adjusted odds ratio, 1.93 [95% confidence interval, 1.07-3.48]). Severe fevers remained associated with composite neonatal morbidity compared with mild fevers after accounting for the duration between reaching maximum intrapartum temperature and delivery (adjusted hazard ratio, 2.05 [95% confidence interval, 1.23-3.43]). Composite neonatal neurologic morbidity and composite maternal morbidity were not different between patients with mild and patients with severe fevers.

CONCLUSION

Composite neonatal morbidity correlated with intrapartum fever severity in a potentially dose-dependent fashion. This correlation was independent of the duration from reaching maximum intrapartum temperature to delivery, suggesting that clinical management of intrapartum fever, in terms of timing or mode of delivery, should not be affected by this duration.

Management of Isolated Fever in Labour Compared with Clinical Chorioamnionitis in a Quaternary Centre

OBJECTIVES

To investigate treatment patterns of women with isolated fever in labour and evaluate if variables in the sepsis in obstetrics score (SOS) or fetal tachycardia are associated with treatment differences. Our secondary objective was to compare women with isolated fever in labour with women with clinical chorioamnionitis to identify any clinicodemographic differences.

METHODS

A retrospective cohort study of 473 patients at BC Women's Hospital who presented with isolated fever in labour between January 2011 and April 2016 compared with a dataset of 1135 women with clinical chorioamnionitis from 2011 to 2016 in the same institution.

RESULTS

In our cohort of isolated fever in labour, antibiotics were given 74.2 % of the time, and the majority received cefazolin and metronidazole (80.9%, of those who received antibiotics). Higher maternal temperature and heart rate at time of first fever and fetal tachycardia were associated with more antibiotic use. Slightly higher maternal temperature was associated with use of a saline bolus and blood cultures. The proportion of women with a SOS greater than 5 increased 4.5-fold from time of first fever to time of maximum SOS. There were fewer cesarean deliveries in the isolated fever in labour group compared with the clinical chorioamnionitis group (22.4% vs. 54.0%; P < 0.0001).

CONCLUSIONS

Slightly higher maternal temperature was associated with increased treatment, including antibiotic use, saline bolus administration, and blood cultures. As evidenced by the higher proportion of women with an SOS over 5, women with isolated fever in labour may have a propensity to deteriorate clinically.

Fetal and maternal inflammatory response in the setting of maternal intrapartum fever with and without clinical and histologic chorioamnionitis

BACKGROUND

Both infectious and noninfectious causes of maternal fever have been linked to adverse neonatal outcomes including low Apg0ar scores, respiratory distress, hypotonia, and neonatal seizures. Even in the absence of infection, the occurrence of intrapartum fever is a strong risk factor for poor long-term neonatal developmental outcomes, including encephalopathy, cerebral palsy, and neonatal death.

OBJECTIVE

The primary objective of this study was to compare intrapartum and postpartum maternal and fetal umbilical cord serum levels of cytokines RANTES, interferon-ɣ, interleukin-1β, interleukin-2, interleukin-4, interleukin-6, interleukin-8, interleukin-10, interleukin-13, and tumor necrosis factor-α among nonfebrile patients, febrile patients without clinical chorioamnionitis, and febrile patient with clinical chorioamnionitis.

STUDY DESIGN

This study was conducted at the Richmond University Medical Center from May 15, 2020 to July 16, 2019. During this time, we recruited 30 nonfebrile patients at >36 gestational weeks who were in labor and collected umbilical cord and pre- and postdelivery maternal serum samples to evaluate the cytokine levels. Placentas were collected for pathologic review and to evaluate the histopathologic findings. These results were compared with 121 patients who developed a fever of >38°C during labor. The febrile patients were further divided based on the presence or absence of clinical chorioamnionitis. A secondary analysis was performed based on the presence of absence of histologic chorioamnionitis. Statistical analysis was performed using IBM Statistical Package for the Social Sciences version 25.0. For the 3 group comparisons, a P value of <.017 was considered statistically significant after application of a Bonferroni correction.

RESULTS

A total of 151 patients were included in the study; 30 were nonfebrile patients, 46 were febrile patients with a diagnosis of clinical chorioamnionitis, and 75 were febrile patients without clinical chorioamnionitis. Compared with nonfebrile patients, umbilical cord serum interferon-ɣ, interleukin-1β, interleukin-6, interleukin-8, RANTES, and tumor necrosis factor-α levels were elevated in the presence of maternal hyperthermia irrespective of the diagnosis of clinical chorioamnionitis. Interleukin-6 umbilical cord levels were more than doubled from 63.60 pg/mL (6.09-1769.03 pg/mL) in febrile patients with no clinical chorioamnionitis to 135.77 pg/mL (1.86-6004.78 pg/mL) in febrile patients with clinical chorioamnionitis, making it the only cytokine that was significantly different between these 2 groups. When comparing the intrapartum maternal serum, we found a significant elevation in the interleukin-10, RANTES, and tumor necrosis factor-α levels in the febrile group irrespective of the presence of clinical chorioamnionitis when compared with the nonfebrile group. In the postpartum maternal blood evaluations, tumor necrosis factor-α was the only cytokine that was significantly higher in febrile patients than in nonfebrile controls.

CONCLUSION

In the setting of intrapartum fever, maternal cytokine profiles were similar irrespective of the diagnosis of clinical chorioamnionitis. Even in the absence of clinical or histologic chorioamnionitis, maternal hyperthermia induced elevations in fetal cytokines.

Study on perinatal-related factors of maternity and newborn in parturients with intrapartum fever in part of Eastern China: A cross-sectional study

Background

Maternal intrapartum fever has a serious impact on mother and child. However, the corresponding study seems to be in short.

Methods

The role of inflammatory cells in patients who were diagnosed with intrapartum fever lived in part of Eastern China was evaluated. The obstetrics outcomes, complete blood cell count (CBC) and thereby converted neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio, monocyte to lymphocyte ratio (MLR), and vaginal secretion were compared in different groups.

Results

Prepartum values of white blood cell (WBC), red blood cell (RBC), and hemoglobin (Hb) were all a little higher in the febrile group than in the afebrile group, and postpartum WBC in the afebrile group was still higher while postpartum RBC and Hb were inferior to non‐fever maternity. Postpartum NLR and MLR were all higher in the fever group but not preferred overtly difference before delivery. Additionally, the comparison of WBC, RBC, Hb, platelets, neutrophils, and monocytes in prepartum and postpartum all showed significant differences.

Conclusion

The parturition could bring about the value change of CBC and intrapartum fever might aggravate or alleviate this change. Besides, the intrapartum fever might not be caused mainly by infection and the difference between bacteria and fungus could reflect in the CBC.

Nomogram for perinatal prediction of intrapartum fever: a retrospective case-control study

Objective

To explore the risk factors for intrapartum fever and to develop a nomogram to predict the incidence of intrapartum fever.

Methods

The general demographic characteristics and perinatal factors of 696 parturients who underwent vaginal birth at the Affiliated Hospital of Xuzhou Medical University from May 2019 to April 2020 were retrospectively analysed. Data was collected from May 2019 to October 2019 on 487 pregnant women who formed a training cohort. A multivariate logistic regression model was used to identify the independent risk factors associated with intrapartum fever during vaginal birth, and a nomogram was developed to predict the occurrence. To verify the nomogram, data was collected from January 2020 to April in 2020 from 209 pregnant women who formed a validation cohort.

Results

The incidence of intrapartum fever in the training cohort was found in 72 of the 487 parturients (14.8%), and the incidence of intrapartum fever in the validation cohort was 31 of the 209 parturients (14.8%). Multivariate logistic regression analysis showed that the following factors were significantly related to intrapartum fever: primiparas (odds ratio [OR] 2.43; 95% confidence interval [CI] 1.15–5.15), epidural labour analgesia (OR 2.89; 95% CI 1.23–6.82), premature rupture of membranes (OR 2.37; 95% CI 1.13–4.95), second stage of labour ≥ 120 min (OR 4.36; 95% CI 1.42–13.41), amniotic fluid pollution degree III (OR 10.39; 95% CI 3.30–32.73), and foetal weight ≥ 4000 g (OR 7.49; 95% CI 2.12–26.54). Based on clinical experience and previous studies, the duration of epidural labour analgesia also appeared to be a meaningful factor for intrapartum fever; therefore, these seven variables were used to develop a nomogram to predict intrapartum fever in parturients. The nomogram achieved a good area under the ROC curve of 0.86 and 0.81 in the training and in the validation cohorts, respectively. Additionally, the nomogram had a well-fitted calibration curve, which also showed excellent diagnostic performance.

Conclusion

We constructed a model to predict the occurrence of fever during childbirth and developed an accessible nomogram to help doctors assess the risk of fever during childbirth. Such assessment may be helpful in implementing reasonable treatment measures.

Trial registration

Clinical Trial Registration: (www.chictr.org.cnChiCTR2000035593)

Risk Factors and Safety Analyses for Intrapartum Fever in Pregnant Women Receiving Epidural Analgesia During Labor

Background

We aimed to explore the factors leading to epidural-related maternal fever and the influence of intrapartum fever on neonates.

Material/Methods

A retrospective analysis was performed on data from pregnant women who received epidural analgesia during labor. The primary aim was to determine the influence of epidural labor analgesia on the incidence of intrapartum fever in pregnant women. The secondary aim was to determine the influence of intrapartum fever on neonates.

Results

Logistic regression analysis showed that premature rupture of membranes (OR=2.008, 95% CI: 1.551–2.600), vaginal examination performed more than 6 times (OR=1.681, 95% CI: 1.286–2.197), long duration of labor (OR=1.090, 95% CI: 1.063–1.118), and long time from rupture of membranes to delivery (OR=1.048, 95% CI: 1.010–1.087) were all risk factors for intrapartum fever in pregnant women with epidural labor analgesia. Regarding the secondary research outcome, the incidence of intrapartum fever was significantly associated with the number of neonates with Apgar score of 10 delivered from pregnant women with epidural labor analgesia (P<0.05). There was no statistically significant difference in the transfer rate of newborns to the Neonatal Intensive Care Unit (NICU) (P>0.05).

Conclusions

Premature rupture of membranes, vaginal examination performed more than 6 times, long duration of labor, and long time from rupture of membranes to delivery are all factors raising the risk of fever during epidural labor analgesia. Although intrapartum fever in the mothers had a significant influence on the number of neonates with Apgar score of 10, it did not affect the outcome of neonates in terms of NICU transfer rate.

Degree of intrapartum fever and associated factors: Three group analysis of no fever, borderline and overt fever

AIM

Previous studies analyzing intrapartum fever by dichotomization of fever just above 38.0°C or not may lead to overlook clinical significance of borderline fever. We aimed to investigate the maternal baseline and intrapartum characteristics, neonatal outcomes, and inflammatory placental pathology in relation to the degree of intrapartum fever by three group analysis.

METHODS

We performed a retrospective analysis of consecutive singleton deliveries between 37^0/7 to 41^0/7 weeks divided into three groups based on the peak body temperature during labor: No fever (< 37.5°C), borderline fever (≥ 37.5°C and < 38.0°C), and overt fever (≥ 38.0°C). Maternal and intrapartum characteristics, neonatal outcomes, and inflammatory placental pathology were compared by trend analysis, intergroup difference analysis, and multivariable analysis.

RESULTS

The degree of intrapartum fever was significantly associated with younger maternal age, nulliparity, longer duration of rupture of membrane, and epidural analgesia (p < 0.001). And the incidence of neonatal proven sepsis and mortality were not significantly different among the groups. The degree of intrapartum fever was associated with the stage of acute chorioamnionitis and funisitis (p < 0.001). Multivariate analysis revealed that the association with epidural analgesia was stronger in borderline fever than overt fever (adjusted odds ratio [95% confidence interval], borderline fever = 18.487 [11.447-29.857]; overt fever = 11.068 [4.874-25.133]) after controlling for maternal age, parity, induction or augmentation, duration of ROM, birth weight, and meconium staining.

CONCLUSION

Our data support that both epidural analgesia and inflammation of the placenta may contribute to the development of intrapartum fever at term.

Concerned topics of epidural labor analgesia: labor elongation and maternal pyrexia: a systematic review

Objective:

Labor is a complex process and labor pain presents challenges for analgesia. Epidural analgesia (EA) has a well-known analgesic effect and is commonly used during labor. This review summarized frequently encountered and controversial problems surrounding EA during labor, including the labor process and maternal intrapartum fever, to build knowledge in this area.

Data sources:

We searched for relevant articles published up to 2019 in PubMed using a range of search terms (eg, “labor pain,” “epidural,” “analgesia,” “labor process,” “maternal pyrexia,” “intrapartum fever”).

Study selection:

The search returned 835 articles, including randomized control trials, retrospective cohort studies, observational studies, and reviews. The articles were screened by title, abstract, and then full-text, with a sample independently screened by two authors. Thirty-eight articles were included in our final analysis; 20 articles concerned the labor process and 18 reported on maternal pyrexia during EA.

Results:

Four classic prospective studies including 14,326 participants compared early and delayed initiation of EA by the incidence of cesarean delivery. Early initiation following an analgesia request was preferred. However, it was controversial whether continuous use of EA in the second stage of labor induced adverse maternal and neonatal outcomes due to changes in analgesic and epidural infusion regimens. There was a high incidence of maternal pyrexia in women receiving EA and women with placental inflammation or histologic chorioamnionitis compared with those receiving systemic opioids.

Conclusions:

Early EA (cervical dilation ≥1 cm) does not increase the risk for cesarean section. Continuous epidural application of low doses of analgesics and programmed intermittent epidural bolus do not prolong second-stage labor duration or impact maternal and neonatal outcomes. The association between EA and maternal pyrexia remains controversial, but pyrexia is more common with EA than without. A non-infectious inflammatory process is an accepted mechanism of epidural-related maternal fever.

Randomized control trial of intravenous acetaminophen for reduction of intrapartum maternal fever

BACKGROUND

Intravenous acetaminophen reaches a higher mean peak plasma concentration than oral acetaminophen in a shorter period of time. The favorable pharmacokinetics of intravenous acetaminophen may be beneficial for treating intrapartum maternal fever.

OBJECTIVE

The primary objective was to compare intravenous and oral acetaminophen in time to defervescence (temperature <38°C). The secondary objective was to compare intravenous and oral acetaminophen in the percentage of participants being afebrile and percent reduction in maternal temperature 30 minutes after administration of first dose. Other outcomes evaluated were histopathological placental findings; neonatal outcomes; oxidative stress; and levels of RANTES, interferon-δ, interleukin 1β, interleukin 2, interleukin 4, interleukin 6, interleukin 8, interleukin 10, interleukin 13, and tumor necrosis factor-α in maternal and neonatal blood.

STUDY DESIGN

This was a randomized, comparator-controlled, double-dummy, double-blind clinical trial. At the onset of intrapartum fever ≥38°C, patients ≥36 weeks' gestation were either randomized to the control or experimental study arm. Patients in the control arm received 1000 mg of oral acetaminophen capsules and an intravenous placebo resembling intravenous acetaminophen. Patients randomized to the experimental arm received 1000 mg of intravenous acetaminophen and oral placebo capsules resembling acetaminophen. Maternal temperatures and fetal heart rates were recorded at consecutive intervals following administration of the first dose of acetaminophen. Maternal blood, collected at the onset of fever and after delivery, and neonatal cord blood collected at delivery were evaluated for oxidative stress (glutathione levels), levels of RANTES and cytokines (interferon-δ, interleukin 1β, interleukin 2, interleukin 4, interleukin 6, interleukin 8, interleukin 10, interleukin 13, and tumor necrosis factor-α). Placentas were collected for pathologic review. A P value of <.05 was considered statically significant.

RESULTS

A total of 121 patients (55 in the intravenous and 66 in the oral group) were recruited from December 1, 2016, to February 28, 2018. Patient demographics and intrapartum factors were similar between both arms. The intravenous group showed a mean time of 54.86 minutes (95% confidence interval, 20.57-39.43) to defervescence vs 52.58 minutes (95% confidence interval, 16.58-43.42) in the oral group (P=.71). In addition, intravenous and oral acetaminophen showed similar results in percentage of patients being afebrile and percent reduction in maternal temperature 30 minutes after administration of the first dose. Histopathological findings, neonatal outcomes, oxidative stress markers, and RANTES and cytokine levels were not statistically significant between intravenous and oral acetaminophen groups.

CONCLUSION

Intravenous acetaminophen did not demonstrate a higher efficacy than oral acetaminophen in treating intrapartum maternal fever. Select patients may benefit from intravenous acetaminophen for treatment of intrapartum fever, including those who cannot tolerate oral medication.

Association of lymphocyte count and incidence of maternal fever in epidural analgesia-involved labor

Background

Evidence showed that the use of epidural analgesia increased the risk of maternal fever during labor, and the potential mechanisms involved inflammation. Lymphocyte played a role in the inflammatory responses, and lymphopenia predicted adverse outcomes for patients. The aim of this study was to investigate whether lymphocyte count was associated with the incidence of intrapartum fever in nulliparous women undergoing vaginal delivery.

Methods

In this retrospective cohort study, electronic medical record data at the International Peace Maternity and Child Health Hospital (IPMCH, Shanghai, China) between 2012 and 2017 were extracted. The primary outcome of this study was baseline lymphocyte count in febrile and afebrile parturients who received labor epidural analgesia. Other confounding factors associated with the development of intrapartum fever were analyzed using multivariable logistic regression.

Results

The final study population consisted of 36,562 parturients, of whom 18,952 (51.8%) received labor epidural analgesia. Labor epidural analgesia was associated with an increased risk of maternal fever [relative risk: 4.55; 95% confidence interval (CI): 4.16–4.98; P<0.001]. Among the parturients who received epidural analgesia, both baseline lymphocyte count and lymphocyte percentage were lower in the febrile patients than those in the afebrile patients (P<0.001; P=0.015). The lower (<1.1×10⁹/L) baseline lymphocyte was associated with a higher risk of maternal fever (adjusted odds ratio: 1.30, 95% CI: 1.14–1.48; P<0.001).

Conclusions

Our results suggested that lower lymphocyte baseline indicated an increased risk of maternal fever during epidural analgesia-involved labor. Further studies are needed to confirm the findings and determine the potential mechanisms.

Epidural analgesia, intrapartum hyperthermia, and neonatal brain injury: a systematic review and meta-analysis

BACKGROUND

Epidural analgesia is associated with intrapartum hyperthermia, and chorioamnionitis is associated with neonatal brain injury. However, it is not known if epidural hyperthermia is associated with neonatal brain injury. This systematic review and meta-analysis investigated three questions: (1) does epidural analgesia cause intrapartum hyperthermia, (2) is intrapartum hyperthermia associated with neonatal brain injury, and (3) is epidural-induced hyperthermia associated with neonatal brain injury?

METHODS

PubMed, ISI Web of Knowledge, The Cochrane Library, and Embase were searched from inception to January 2020 using Medical Subject Headings (MeSH) terms relating to epidural analgesia, hyperthermia, labour, and neonatal brain injury. Studies were reviewed independently for inclusion and quality by two authors (Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach). Two meta-analyses were performed using the Mantel-Haenszel fixed effect method to generate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Forty-one studies were included for Question 1 (646 296 participants), 36 for Question 2 (11 866 021 participants), and two studies for Question 3 (297 113 participants). When the mode of analgesia was randomised, epidural analgesia was associated with intrapartum hyperthermia (OR: 4.21; 95% CI: 3.48-5.09). There was an association between intrapartum hyperthermia and neonatal brain injury (OR: 2.79; 95% CI: 2.54-2.3.06). It was not possible to quantify the association between epidural-induced hyperthermia and neonatal brain injury.

CONCLUSIONS

Epidural analgesia is a cause of intrapartum hyperthermia, and intrapartum hyperthermia of any cause is associated with neonatal brain injury. Further work is required to establish if epidural-induced hyperthermia is a cause of neonatal brain injury.

Key indicators influencing management of prolonged second stage labour by midwives in freestanding birth centres: Results from an ethnographic interview study

PROBLEMS

Complications for newborns and postpartum clients in the hospital are more frequent after a prolonged second stage of labour. Midwives in community settings have little research to guide management in their settings.

AIM

We explored how US birth centre midwives identify onset of second stage of labour and determine when to transfer clients to the hospital for prolonged second stage.

METHODS

Ethnographic interviews of midwives with at least 2 years' experience in birth centres and participant observation of birth centre care.

FINDINGS

We interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives' decision-making about transfers.

DISCUSSION & CONCLUSION

These findings can inform future robust multivariate evaluation of factors, including but not limited to time, in guidelines for management of second stage of labour. Optimal management may require formal consideration of more than just time and parity. Our findings also suggest the need for evaluation of how structural issues involving hospital privileges for midwives and relationships between birth centre and hospital staff affect the well-being of childbearing families.

Remifentanil patient-controlled versus epidural analgesia on intrapartum maternal fever: a systematic review and meta-analysis

Background

Intravenous remifentanil patient-controlled analgesia (RPCA) is an alternative for epidural analgesia (EA) in labor pain relief. However, it remains unknown whether RPCA is superior to EA in decreasing the risk of intrapartum maternal fever during labor.

Methods

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review and meta-analysis was performed by searching PubMed, EMBASE and the Cochrane Central Register of Controlled Trials from inception to April 2019. All randomized controlled trials (RCTs) investigating the risk of intrapartum maternal fever with RPCA compared with EA alone or EA in combination with spinal analgesia during labor were included.

Results

A total of 825 studies were screened, and 6 RCTs including 3341 patients were identified. Compared with EA, RPCA was associated with a significantly lower incidence of intrapartum maternal fever (risk ratio [RR] 0.48, P = 0.02, I² = 49%) during labor analgesia. After excluding 2 trials via the heterogeneity analysis, there was no difference in the incidence of intrapartum fever between patients receiving RPCA and those receiving EA. Satisfaction with pain relief during labor was lower in the RPCA group than that in the EA group (− 10.6 [13.87, − 7.44], P < 0.00001, I² = 0%). The incidence of respiratory depression was significantly greater in the RPCA group than that in the EA group (risk ratio 2.86 [1.65, 4.96], P = 0.0002, I² = 58%). The incidence of Apgar scores < 7 at 5 min in the RPCA group was equivalent to that in the EA group.

Conclusion

There is no solid evidence to illustrate that the incidence of intrapartum maternal fever is lower in patients receiving intravenous RPCA than in patients receiving EA.

Epidural-Related Fever and Maternal and Neonatal Morbidity: A Systematic Review and Meta-Analysis

BACKGROUND

While epidural analgesia (EA) is associated with maternal fever during labor, the impact on the risk for maternal and/or neonatal sepsis is unknown.

OBJECTIVES

The aim of this systematic review was to investigate the effect of epidural-related intrapartum fever on maternal and neonatal outcomes.

METHODS

OVID MEDLINE, OVID Embase, the Cochrane Library, Cochrane Controlled Register of Trials, and clinical trial registries were searched for randomized controlled trials (RCT) and observational cohort studies from inception to November 2018. A total of 761 studies were identified with 100 eligible for full-text review. Only articles investigating the relationship between EA and maternal fever during labor were eligible for inclusion. Study quality was assessed using the Cochrane's Risk of Bias tool and National Institute of Health Quality Assessment Tool. Two meta-analyses - one each for the RCT and observational cohort groups - were performed using the random-effects model of Mantel-Haenszel to produce summary risk ratios (RR) with 95% CI.

RESULTS

Twelve RCTs and 16 observational cohort studies involving 579,157 parturients were included. RRs for maternal fever for the RCT and cohort analyses were 3.54 (95% CI 2.61-4.81) and 5.60 (95% CI 4.50-6.97), respectively. Meta-analyses of RR for maternal infection in both groups were infeasible given few occurrences. Meta-analysis of data from observational studies showed an increased risk for maternal antibiotic treatment in the epidural group (RR 2.60; 95% CI 1.31-5.17). For both analyses, neonates born to women with an epidural were not evaluated more often for suspected sepsis. Neither analysis reported an increased rate of neonatal bacteremia or neonatal antibiotic treatment after EA, although data precluded conclusiveness.

CONCLUSION

EA increases the risk of intrapartum fever and maternal antibiotic treatment. However, a definite conclusion on whether EA increases the risk for a proven maternal and/or neonatal bacteremia cannot be drawn due to the low quality of data. Further research on whether epidural-related intrapartum fever is of infectious origin or not is therefore needed.

Average and time-specific maternal prenatal inflammatory biomarkers and the risk of labor epidural associated fever

Background

The use of labor epidural analgesia has been associated with intrapartum fever, known as labor epidural associated fever (LEAF). LEAF is most commonly non-infectious in origin and associated with elevated inflammatory cytokines.

Methods

The LIFECODES pregnancy cohort was designed to prospectively collect data to evaluate the association of maternal inflammatory biomarkers with preterm birth in women who delivered between 2007 and 2008 at Brigham and Women’s Hospital. Our secondary analysis of the data from the cohort identified 182 women for whom inflammatory biomarkers (i.e. interleukin-10, interleukin-1β, interleukin-6, tumor necrosis factor-α and C-reactive protein) collected longitudinally over four prenatal visits was available. Maternal temperature and other clinical variables were abstracted from medical records. The primary outcome, the presence of LEAF, was defined as oral temperature ≥ 38°C (≥100.4°F) after epidural analgesia initiation. Multivariable logistic regression estimated the association between inflammatory biomarker concentrations and the odds of developing an intrapartum fever after adjusting for a number of potential confounders.

Results

Women who developed LEAF were more likely to have a longer duration of epidural analgesia, whereas women who did not develop LEAF were more likely to have induced labor and positive or unknown Group B Streptococcus colonization status. However, no differences were seen by nulliparity, mode of delivery, white blood cell count at admission, baseline temperature, length of rupture of membranes and number of cervical exams performed during labor. Unadjusted and multivariable logistic regression models did not provide evidence for or exclude an association between individual maternal inflammatory biomarkers and the odds of developing LEAF, regardless of visit time-period.

Conclusion

The predictive value of maternal inflammatory biomarkers measured during early- and mid-pregnancy for the risk of developing LEAF cannot be excluded.

Epidural Labor Analgesia and Maternal Fever

Women receiving an epidural for labor analgesia are at increased risk for intrapartum fever. This relationship has been supported by observational, before and after, and randomized controlled trials. The etiology is not well understood but is likely a result of noninfectious inflammation as studies have found women with fever have higher levels of inflammatory markers. Maternal pyrexia may change obstetric management and women are more likely to receive antibiotics or undergo cesarean delivery. Maternal pyrexia is associated with adverse neonatal outcomes. With these consequences, understanding and preventing maternal fever is imperative.

Achieving competency in vaginal examinations: The challenge of balancing student learning needs with best practice in maternity care

Assessment of labor progress through vaginal digital examination (VE) remains one of the most challenging skills for midwifery students. As VE during labor has become a less frequent occurrence there are less opportunities for student midwives to gain mastery of the skill. Best practices for teaching and evaluating VE involve a step-wise, multi modal approach. More research is needed on how to standardize teaching for this essential skill.

Fetal and maternal temperatures during labor and delivery: a prospective descriptive study

OBJECTIVE

The objective of this study is to study the fetal scalp temperature (FST) and maternal axillary temperature (MAT) during vaginal delivery relative to progression of labor, uterine contractions (UC) and epidural analgesia (EDA), and to construct normal temperature reference ranges related to stage of labor.

MATERIAL AND METHODS

Temperatures were recorded continuously in labor of 132 women with a bi-metal temperature sensor attached to the axilla (MAT) and a similar sensor mounted in a scalp electrode (FST). The temperature data were stored electronically and analyzed offline at cervical dilatations of 2-3, 5, 7-8, and 10 cm, and at full retraction. The FST was read before, at increasing, at peak, at decreasing, and after UC. The MAT and FST curves were compared with mixed-effect models statistics for repeated measurements. A two-tailed p <.05 was considered significant.

RESULTS

The FST did not vary during UC (p = .24). Both FST and MAT increased linearly by progression of labor (both p < .001). The increases in temperatures were greater with EDA than without (p < .001).

CONCLUSIONS

During UC, the FST showed no alteration. Both FST and MAT increased significantly by progression of labor, and significantly more in the presence of EDA. The presented normal temperature reference ranges can be used for future research.

Risk Factors for Intrapartum Fever in Term Gestations and Associated Maternal and Neonatal Sequelae

AIM

To determine factors associated with intrapartum fever and to examine associated maternal and neonatal outcomes.

METHODS

Retrospective study of patients between 360/7 and 420/7 gestational weeks who entered spontaneous or induced active labor and developed temperature ≥38°C; a similar group that did not develop fever were controls. Univariate and multivariate analyses were performed with p < 0.05 as significant.

RESULTS

Fifty-four febrile patients and 306 nonfebrile controls met inclusion criteria. Nulligravidity (45.8 vs. 77.8%, p < 0.001), length of first stage ≥720 min (OR 3.59, 95% CI 1.97-6.55, p < 0.001), length of second stage ≥120 min (OR 4.76, 95% CI 2.29-9.89, p < 0.001), membrane rupture ≥240 min (46.4 vs. 79.6%, p < 0.001), increasing number of vaginal exams (4 vs. 6, p < 0.001), oxytocin (44.8 vs. 63.0%, p = 0.014), and meperidine (14.7 vs. 35.2%, p < 0.001) were all associated with intrapartum fever. Associated morbidity included cesarean delivery (22.5 vs. 44.4%, p = 0.001), Apgar score <7 at 5 min (0.7 vs. 5.6%, p = 0.011), and neonatal intensive care unit admission (9.5 vs. 51.9%, p < 0.001).

CONCLUSION

We have identified several noninfectious factors that are associated with intrapartum fever. Modification of risk factors may improve both maternal and neonatal outcomes.

Labor Epidural Analgesia and Breastfeeding: A Systematic Review

Despite widespread use of epidural analgesia during labor, no consensus has been reached among obstetric and anesthesia providers regarding its effects on breastfeeding. The purpose of this review was to examine the relationship between labor epidural analgesia and breastfeeding in the immediate postpartum period. PubMed, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature were searched for articles published in 1990 or thereafter, using the search term breastfeeding combined with epidural, labor epidural analgesia, labor analgesia, or epidural analgesia Of 117 articles, 23 described empirical studies specific to labor epidural analgesia and measured a breastfeeding outcome. Results were conflicting: 12 studies showed negative associations between epidural analgesia and breastfeeding success, 10 studies showed no effect, and 1 study showed a positive association. Most studies were observational. Of 3 randomized controlled studies, randomization methods were inadequate in 2 and not evaluable in 1. Other limitations were related to small sample size or inadequate study power; variation and lack of information regarding type and dosage of analgesia or use of other intrapartum interventions; differences in timing, definition, and method of assessing breastfeeding success; or failure to consider factors such as mothers' intention to breastfeed, social support, siblings, or the mother's need to return to work or school. It is also unclear to what extent results are mediated through effects on infant neurobehavior, maternal fever, oxytocin release, duration of labor, and need for instrumental delivery. Clinician awareness of factors affecting breastfeeding can help identify women at risk for breastfeeding difficulties in order to target support and resources effectively.

Chorioamnionitis at Term: Definition, Diagnosis, and Implications for Practice

Chorioamnionitis is a serious complication during labor at term and is associated with adverse neonatal outcome affecting approximately 10% of pregnancies. It is diagnosed clinically or microbiologically or by histopathologic examination of the placenta and umbilical cord. The clinical criteria for chorioamnionitis found in preterm or term women include maternal fever combined with 2 or more findings of maternal tachycardia, fetal tachycardia, leukocytosis, uterine tenderness, and/or malodorous amniotic fluid. These subjective findings are neither sensitive nor specific. However, clinical chorioamnionitis requires a high index of suspicion, timely diagnosis, prompt antibiotic treatment, and delivery, which may help reduce the potentially devastating outcome of maternal and neonatal infections. This article focuses on clinical chorioamnionitis and presents the physiologic immune response during pregnancy, the definition of chorioamnionitis, clinical diagnostic criteria, and implications for practice.