- Katherine T Chen, MD, MPH
Katherine T Chen, MD, MPH
- Professor of Obstetrics, Gynecology, and Reproductive Science
- Icahn School of Medicine at Mount Sinai
- Section Editors
- Susan M Ramin, MD
Susan M Ramin, MD
- Section Editor — Obstetrics
- Professor of Obstetrics and Gynecology
- Baylor College of Medicine
- David L Hepner, MD
David L Hepner, MD
- Section Editor — Obstetric Anesthesia
- Associate Professor of Anaesthesia
- Harvard Medical School
Intrapartum fever (ie, fever during labor) can be due to an infectious or non-infectious etiology and can lead to a variety of maternal and neonatal sequelae. Numerous risk factors for intrapartum fever have been reported, such as nulliparity, prolonged labor, and premature rupture of membranes . These characteristics describe women likely to develop intraamniotic infection (IAI) and/or receive epidural anesthesia, which are the two common causes of intrapartum fever. In the absence of a preexisting febrile disorder (eg, respiratory infection), most pregnant women who develop fever in labor are presumed to have IAI and treated with broad spectrum antibiotics.
The vast majority of patients with elevated body temperature have fever, which occurs when the hypothalamic thermoregulatory center is reset at a higher temperature by "endogenous pyrogens" produced by specific host cells in response to infection, inflammation, injury, or antigenic challenge. These pyrogenic polypeptides include the cytokines interleukin (IL)-1 alpha and IL-1 beta, IL-6, tumor necrosis factor (TNF)-alpha and TNF-beta, and interferon alpha [2,3].
There are a few instances in which an elevated temperature represents hyperthermia rather than fever. As an example, some pharmacologic agents (eg, atropine, the recreational drug "ecstasy") raise core temperature by blocking sweating or vasodilation without changing the normal hypothalamic set-point. (See "Pathophysiology and treatment of fever in adults" and "Drug fever".)
For the purposes of this discussion, the term fever will generally be used to describe maternal intrapartum temperature elevation from any mechanism.
Fever is defined as an elevation of body temperature above normal daily variation. The threshold for intrapartum fever has generally been considered to be maternal temperature ≥38 degrees C (≥100.4 degrees F) orally. This is based, in part, on a study of temperature in normal parturients, which ranged from 34.6 to 37.6 degrees C (94.3 to 99.7 degrees F) upon admission to the labor unit . There was a diurnal distribution, with a peak from midnight to 2 AM and a nadir from 11 AM to noon.
- Maayan-Metzger A, Mazkereth R, Shani A, Kuint J. Risk factors for maternal intrapartum fever and short-term neonatal outcome. Fetal Pediatr Pathol 2006; 25:169.
- Smulian JC, Bhandari V, Vintzileos AM, et al. Intrapartum fever at term: serum and histologic markers of inflammation. Am J Obstet Gynecol 2003; 188:269.
- Saper CB, Breder CD. The neurologic basis of fever. N Engl J Med 1994; 330:1880.
- Acker DB, Schulman EB, Ransil BJ, et al. The normal parturient's admission temperature. Am J Obstet Gynecol 1987; 157:308.
- Higgins RD, Saade G, Polin RA, et al. Evaluation and Management of Women and Newborns With a Maternal Diagnosis of Chorioamnionitis: Summary of a Workshop. Obstet Gynecol 2016; 127:426.
- Petrova A, Demissie K, Rhoads GG, et al. Association of maternal fever during labor with neonatal and infant morbidity and mortality. Obstet Gynecol 2001; 98:20.
- Lieberman E, Lang J, Richardson DK, et al. Intrapartum maternal fever and neonatal outcome. Pediatrics 2000; 105:8.
- Yancey MK, Zhang J, Schwarz J, et al. Labor epidural analgesia and intrapartum maternal hyperthermia. Obstet Gynecol 2001; 98:763.
- Sharma SK, Sidawi JE, Ramin SM, et al. Cesarean delivery: a randomized trial of epidural versus patient-controlled meperidine analgesia during labor. Anesthesiology 1997; 87:487.
- Sharma SK, Alexander JM, Messick G, et al. Cesarean delivery: a randomized trial of epidural analgesia versus intravenous meperidine analgesia during labor in nulliparous women. Anesthesiology 2002; 96:546.
- Ramin SM, Gambling DR, Lucas MJ, et al. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol 1995; 86:783.
- Banerjee S, Cashman P, Yentis SM, Steer PJ. Maternal temperature monitoring during labor: concordance and variability among monitoring sites. Obstet Gynecol 2004; 103:287.
- Sciscione AC, Zainia T, Leet T, et al. A new device for measuring intrauterine temperature. Am J Obstet Gynecol 2001; 184:1431.
- Macaulay JH, Randall NR, Bond K, Steer PJ. Continuous monitoring of fetal temperature by noninvasive probe and its relationship to maternal temperature, fetal heart rate, and cord arterial oxygen and pH. Obstet Gynecol 1992; 79:469.
- ADAMSON SK Jr, TOWELL ME. THERMAL HOMEOSTASIS IN THE FETUS AND NEWBORN. Anesthesiology 1965; 26:531.
- Walker D, Walker A, Wood C. Temperature of the human fetus. J Obstet Gynaecol Br Commonw 1969; 76:503.
- Davie A, Amoore J. Best practice in the measurement of body temperature. Nurs Stand 2010; 24:42.
- Wartzek T, Mühlsteff J, Imhoff M. Temperature measurement. Biomed Tech (Berl) 2011; 56:241.
- Buhimschi CS, Abdel-Razeq S, Cackovic M, et al. Fetal heart rate monitoring patterns in women with amniotic fluid proteomic profiles indicative of inflammation. Am J Perinatol 2008; 25:359.
- Miyake H, Nakai A, Takeshita T. Fetal heart rate monitoring as a predictor of histopathologic chorioamnionitis in the third trimester. J Nippon Med Sch 2008; 75:106.
- Molberg P, Johnson C, Brown TS. Leukocytosis in labor: what are its implications? Fam Pract Res J 1994; 14:229.
- Acker DB, Johnson MP, Sachs BP, Friedman EA. The leukocyte count in labor. Am J Obstet Gynecol 1985; 153:737.
- Shapiro NI, Wolfe RE, Wright SB, et al. Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med 2008; 35:255.
- Sheffield JS. Sepsis and septic shock in pregnancy. Crit Care Clin 2004; 20:651.
- Bates DW, Sands K, Miller E, et al. Predicting bacteremia in patients with sepsis syndrome. Academic Medical Center Consortium Sepsis Project Working Group. J Infect Dis 1997; 176:1538.
- Leibovici L, Greenshtain S, Cohen O, et al. Bacteremia in febrile patients. A clinical model for diagnosis. Arch Intern Med 1991; 151:1801.
- Smith-Elekes S, Weinstein MP. Blood cultures. Infect Dis Clin North Am 1993; 7:221.
- Kankuri E, Kurki T, Carlson P, Hiilesmaa V. Incidence, treatment and outcome of peripartum sepsis. Acta Obstet Gynecol Scand 2003; 82:730.
- Hurlbut TA 3rd, Littenberg B. The diagnostic accuracy of rapid dipstick tests to predict urinary tract infection. Am J Clin Pathol 1991; 96:582.
- Evers AC, Nijhuis L, Koster MP, et al. Intrapartum fever at term: diagnostic markers to individualize the risk of fetal infection: a review. Obstet Gynecol Surv 2012; 67:187.
- Newton ER. Chorioamnionitis and intraamniotic infection. Clin Obstet Gynecol 1993; 36:795.
- Goetzl L. Epidural analgesia and maternal fever: a clinical and research update. Curr Opin Anaesthesiol 2012; 25:292.
- Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 2011; :CD000331.
- Segal S. Labor epidural analgesia and maternal fever. Anesth Analg 2010; 111:1467.
- Goetzl L, Evans T, Rivers J, et al. Elevated maternal and fetal serum interleukin-6 levels are associated with epidural fever. Am J Obstet Gynecol 2002; 187:834.
- De Jongh RF, Bosmans EP, Puylaert MJ, et al. The influence of anaesthetic techniques and type of delivery on peripartum serum interleukin-6 concentrations. Acta Anaesthesiol Scand 1997; 41:853.
- Sultan P, David AL, Fernando R, Ackland GL. Inflammation and Epidural-Related Maternal Fever: Proposed Mechanisms. Anesth Analg 2016; 122:1546.
- Sessler DI. Temperature monitoring and perioperative thermoregulation. Anesthesiology 2008; 109:318.
- Lieberman E, Lang JM, Frigoletto F Jr, et al. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics 1997; 99:415.
- Goetzl L, Rivers J, Zighelboim I, et al. Intrapartum epidural analgesia and maternal temperature regulation. Obstet Gynecol 2007; 109:687.
- Lee HL, Lo LM, Chou CC, Chuah EC. Comparison between 0.08% ropivacaine and 0.06% levobupivacaine for epidural analgesia during nulliparous labor: a retrospective study in a single center. Chang Gung Med J 2011; 34:286.
- Wong CA, Scavone BM, Peaceman AM, et al. The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med 2005; 352:655.
- Goetzl L, Rivers J, Evans T, et al. Prophylactic acetaminophen does not prevent epidural fever in nulliparous women: a double-blind placebo-controlled trial. J Perinatol 2004; 24:471.
- Sharma SK, Rogers BB, Alexander JM, et al. A randomized trial of the effects of antibiotic prophylaxis on epidural-related fever in labor. Anesth Analg 2014; 118:604.
- Goetzl L, Zighelboim I, Badell M, et al. Maternal corticosteroids to prevent intrauterine exposure to hyperthermia and inflammation: a randomized, double-blind, placebo-controlled trial. Am J Obstet Gynecol 2006; 195:1031.
- Wang LZ, Hu XX, Liu X, et al. Influence of epidural dexamethasone on maternal temperature and serum cytokine concentration after labor epidural analgesia. Int J Gynaecol Obstet 2011; 113:40.
- Goetzl L. Epidural fever in obstetric patients: it's a hot topic. Anesth Analg 2014; 118:494.
- Heesen M, Klöhr S, Rossaint R, et al. Labour epidural analgesia and anti-infectious management of the neonate: a meta-analysis. J Perinat Med 2012; 40:625.
- Palanisamy A, Hepner DL, Segal S. Fever, epidurals, and inflammation: a burning issue. J Clin Anesth 2007; 19:165.
- Kaul B, Vallejo M, Ramanathan S, Mandell G. Epidural labor analgesia and neonatal sepsis evaluation rate: a quality improvement study. Anesth Analg 2001; 93:986.
- Tarshis J, Camann WR, Datta S. Epidural analgesia and neonatal fever. Pediatrics 1998; 101:490.
- Apantaku O, Mulik V. Maternal intra-partum fever. J Obstet Gynaecol 2007; 27:12.
- Greenwell EA, Wyshak G, Ringer SA, et al. Intrapartum temperature elevation, epidural use, and adverse outcome in term infants. Pediatrics 2012; 129:e447.
- Impey L, Greenwood C, MacQuillan K, et al. Fever in labour and neonatal encephalopathy: a prospective cohort study. BJOG 2001; 108:594.
- Impey LW, Greenwood CE, Black RS, et al. The relationship between intrapartum maternal fever and neonatal acidosis as risk factors for neonatal encephalopathy. Am J Obstet Gynecol 2008; 198:49.e1.
- Grether JK, Nelson KB. Maternal infection and cerebral palsy in infants of normal birth weight. JAMA 1997; 278:207.
- Lieberman E, Eichenwald E, Mathur G, et al. Intrapartum fever and unexplained seizures in term infants. Pediatrics 2000; 106:983.
- Lieberman E, Cohen A, Lang J, et al. Maternal intrapartum temperature elevation as a risk factor for cesarean delivery and assisted vaginal delivery. Am J Public Health 1999; 89:506.
- TEMPERATURE MEASUREMENT
- DIAGNOSTIC EVALUATION
- History and physical
- - White blood cell (WBC) count and differential
- - Blood cultures
- - Urine testing
- - Sputum testing
- - Influenza testing
- - Amniotic fluid testing
- - Biological markers
- ETIOLOGY AND MANAGEMENT
- Supportive care
- Infectious etiologies
- - Intraamniotic infection (chorioamnionitis)
- - Urinary tract infection
- - Respiratory tract infection
- Noninfectious etiologies
- - Use of epidural anesthesia
- Newborn issues
- - Labor or delivery in an overheated room
- - Drug fever
- FETAL/NEONATAL CONSEQUENCES
- Infection related maternal fever
- Epidural related maternal fever
- MATERNAL CONSEQUENCES
- SUMMARY AND RECOMMENDATIONS