Readers comment on epidural and fever

In response to my recent post on the risks of fever in epidural, Veronica, a Birth Sense reader,  made an excellent point:

This has been bothering me for the last few days.  If your advice is to get an epidural at 8cms, how likely is it that mother will have that epidural in place and feel any relief before she’s pushing?  Even in a perfect world, if mom already has an IV in, and the anesthesiologist is standing right outside the door, by the time the IV is started enough to start placing the epidural, and by the time everything is in place and the medication is starting to work, wouldn’t you agree that most moms would probably already be pushing or really close to pushing, or even DONE pushing?  Well, unless the epidural causes mom to stall at 8 cms.
I completely agree with the rest of your post, but that’s a very late point in transition to think about an epidural.  It just highlights the considerations that must be made when considering pain medication.  

 Veronica has  made a very good point, and I realize I need to clarify my statements. My advice to wait until 8 cm. until getting an epidural was meant for first-time mothers, who should have time to get an epidural at 8 cm. and get relief before it is time to push.  In the hospital where I practice, we have anesthesia immediately available.  If a woman knows she wants an epidural for labor but wishes to avoid epidural fever, she should already have an IV in place before she is ready for the epidural.

 Since incidence of fever begins to rise  significantly at four hours after epidural administration, I based my recommendation on the average of a centimeter an hour dilation for a first labor, plus two hours of pushing. This would total four hours of epidural administration. Of course, some labors will be faster and some slower, but this is probably a fair estimate for a first time mother. For women who’ve had babies before, fever was not seen as often because their labors tend to be faster and the epidural generally is not in place as long.

If a woman has had a baby before, and wants an epidural, I’d recommend getting it by 6 cm. unless her labor seems to be progressing very slowly. In that case, she should consider if she needs the epidural at that point for pain relief, and if not, I would wait a bit longer.

I don’t believe that women should never get an epidural before 8 centimeters.  For those who want to reduce the risk of epidural-induced fever, timing should be a consideration.  As with any suggestion for intervention in birth,  all the risks and benefits need to be weighed, as well as the individual situation and the reasons for the epidural. I believe there are several occasions where an epidural is valuable, and may even avert a cesarean section:

• When labor has been prolonged, the mother has not slept, and is exhausted.
• When labor is unusually painful, such as back labor.
• When procedures are planned which will be exceptionally painful for the mother, such as needing to manually turn a baby or doing extensive repair of the perineum after birth (I had this situation with a Somali woman who had had a severe laceration with a prior birth, which had never been repaired  We planned to repair it after delivery).
• When a woman has been the victim of sexual assualt or abuse, and has difficulty tolerating a cervical exam or the sensations of the baby moving through the pelvis.
• When a woman reaches the point she feels she is suffering with the pain rather than being able to cope.
• When a woman must have a cesarean section.  An epidural or spinal allows her to be awake and aware, but comfortable, during the surgery.

I appreciate your comments, Veronica, and agree with you that all of these considerations highlight the need to weigh carefully our use of pain medication or any other intervention in labor.

Another reader, an anesthesiologist, wrote:

I found your post contained a few very useful factoids regarding epidurals and fevers.  Unfortunately, I really was dissapointed that it seemed to be more alarmist than necessary. While it is true that many studies have found that maternal fever and epidurals do correlate, the fact that epidurals cause the maternal fever has not been proven.  But more importantly, studies have not shown that patients who have an epidural are at a higher risk for any of the negative outcomes you correlated with those mothers who have fevers.  There was a study published in 1997 that did find an increase frequency of workup in neonates for sepsis if their mother had an epidural, but a subsequent study was not able to show this.

I have been practicing anesthesia for several years, and in practice, I do not see a negative impact on mothers due to maternal fevers. I choose to follow ACOGs published guideline stating that if a mother asks for an epidural, it should not be denied, even if early in labor.

Certainly, I don’t have a problem for any women who chooses to wait until she is 8 cm, but placing an epidural in a women who is at 8 cm is far more difficult and potentially risky than placing one in a a women whose contractions have not yet reached a point that she can hardly sit still.

I’d like to clarify that I do not believe that any mother who wants an epidural should be refused.  My goal is not to prevent women from having epidurals, but to help educate women so they know what the risks and benefits are.  Yes, women are handed an informed consent to sign when they request the epidural, but at that point, many are in pain and not really hearing what the informed consent consists of.  I believe that informed consent for an epidural should be obtained prenatally, in the office, where there is ample time to review the consent form and make sure it is clear. 

In the facility where I work, fever is listed as one of the potential risks of epidural.  Even if epidural does not cause fever, several studies have established an increased incidence of fever when a woman has an epidural, particularly if the epidural is in use for more than a few hours.  In our facility, many newborns do receive a sepsis workup if the mother had a fever in labor, even though we know that these fevers are often benign.  I’m sure this differs somewhat from one facility to the next, but the following studies do report higher rates of neonatal sepsis workups when there was a maternal fever during epidural:

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