Intrapartum temperature elevation, epidural use, and adverse outcome in term infants

Cooling treatment on the reduction of category II fetal tracings

OBJECTIVES

Epidural-related maternal fever increases the incidence of Category II fetal tracings. To compare the effectiveness of low-flow oxygen inhalation and cooling treatment for parturients with Category II fetal tracings caused by epidural-related maternal fever.

METHODS

We investigated 200 pregnant women who accepted epidural analgesia during labor and had body temperature exceeding 38 °C during labor. Among the patients, 99 and 101 were randomly allocated to receive cooling treatment group (control group) and oxygen inhalation (oxygen group), respectively. The primary outcome was the incidence of Category II fetal heart rate tracings.

RESULTS

The incidence of Category II fetal heart rate tracings in the control group was significantly higher than that in the oxygen group. However, no significant differences were noted between the two groups in terms of the Apgar scores; amniotic fluid turbidity; or maternal outcomes, including cesarean section rate, forceps delivery rate, lateral resection rate, manual removal of placenta rate, the amount of intrapartum hemorrhage, and hemorrhage at postpartum 2 h. Oxygen inhalation therapy was more effective than cooling treatment in reducing the incidence of Category II tracings.

CONCLUSION

Low-flow and short-term oxygen inhalation for parturients with epidural-related maternal fever reduces the incidence of Category II fetal heart rate tracings, but had no significant influence on the mode of delivery or neonatal outcomes.

Global research trends in labor analgesia: A bibliometric analysis from 2013 to 2023

Objective

In the past decade, thousands of original articles focus on labor analgesia have published. However, little has been published in the literature that includes a bibliometric analysis of labor analgesia. Therefore, this study is designed to analyze the current status of research on labor analgesia over the past ten years and explore potential directions for the future.

Methods

We retrieved the Web of Science Core Collection (WOSCC) for labor analgesia articles published from 2013 to 2023 and extracted the data from the literature. To perform the bibliometric analysis, we used CiteSpace (6.2. R5) and VOS viewer (1.6.19) as our primary analysis tools.

Results

A total of 2406 articles were included, and the number of publications has increased steadily in the last ten years. The United States was the leading contributor to the area, and Harvard University was the most productive institution. The American Journal of Obstetrics and Gynecology was the most cited and influential journal. The most co-cited reference was "Epidural versus non-epidural or no analgesia for pain management in labour". The labels of the co-citation cluster have identified the characteristics of 5major clusters, such as "postpartum depression", "programmed intermittent epidural bolus", "childbirth experience" "intrapartum maternal fever" and "dural puncture", which play important roles in this field. Keywords co-occurrence and keywords burst detection showed that "vaginal birth", "postpartum depression", "maternal fever", "inflammation", "systematic review", "guidelines", "decreased risk" and "scale" were the most recent and most prominent topics of labor analgesia.

Discussion

This study provided a global review of labor analgesia using bibliometric and visual techniques to provide an intuitive understanding of this topic and identify hotspots and research trends. Notably, intrapartum fever and postpartum depression have emerged as hotpots and trends in labor analgesia research, reflecting the current research landscape.

Epidural Analgesia During Labor and Neonatal Hypoxic-Ischemic Encephalopathy

Importance

Epidural analgesia is used by approximately 70% of birthing persons in the US to alleviate labor pain and is a common cause of elevated temperature in the birthing parent during labor, which, in turn, is associated with adverse neonatal outcomes such as hypoxic-ischemic encephalopathy (HIE).

Objective

To determine whether epidural analgesia is associated with increased risk of HIE after adjusting for the birthing person's maximal temperature before epidural placement and for the propensity to get an epidural.

Design, Setting, and Participants

This retrospective, population-based cohort study was conducted at 15 Kaiser Permanente Northern California hospitals. Participants included singleton neonates born at 35 weeks' or later gestational age between 2012 and 2019. Elective cesarean deliveries and deliveries within 2 hours of hospital admission were excluded. Data analysis was performed from November 2022 to June 2024.

Exposure

The primary exposure was epidural analgesia during labor.

Main Outcomes and Measures

The primary outcome was HIE, defined as the presence of both neonatal acidosis (ie, pH <7 or base deficit ≥10) and encephalopathy. The presence and timing of epidural analgesia and demographic, pregnancy, and labor characteristics were extracted from electronic medical records. A propensity score for receiving epidural analgesia was created including demographic variables and comorbidities predating epidural placement. Logistic regression was used to evaluate the association between epidural analgesia and HIE, adjusting for maximal birthing parent's temperature before epidural placement and the propensity for receiving an epidural.

Results

Among 233 056 infants born at 35 weeks' or later gestational age by vaginal or unplanned cesarean delivery after at least 2 hours of in-hospital labor, 177 603 (76%) were exposed to epidural analgesia and 439 (0.19%) had HIE. On unadjusted analysis, epidural analgesia was associated with an increased risk of maximal temperature greater than 38 °C during labor (risk ratio [RR], 8.58; 95% CI, 8.06-9.14). Each degree increase in maximal temperature during labor was associated with nearly triple the odds of HIE (odds ratio [OR], 2.82; 95% CI, 2.51-3.17). However, there was no significant association between epidural analgesia and the risk of HIE either on crude (RR, 1.21; 95% CI, 0.96-1.53) or adjusted (adjusted OR, 0.93; 95% CI, 0.73-1.17) analyses.

Conclusions and Relevance

In this cohort study including more than 230 000 parent-infant dyads, epidural analgesia was associated with increased maximal temperature during labor, a known risk factor for HIE. However, epidural analgesia was not associated with increased odds of HIE.

Group B Streptococcus and Intraamniotic Inflammation and Infection

Intraamniotic inflammation and infection complicate 2% to 5% of term deliveries. Group B Streptococcus (GBS) is a common cause of intraamniotic infection associated with invasive neonatal disease and maternal morbidity. Universal vaginal-rectal screening for GBS colonization is recommended between 36 and 37 weeks. Intrapartum antibiotic prophylaxis is recommended for individuals with positive GBS screens and other risk factors. Intravenous penicillin is the preferred antimicrobial agent. Individuals with penicillin allergies may receive cefazolin for low-risk allergies and either clindamycin or vancomycin for high-risk allergies, depending on their antimicrobial susceptibilities. Clinical trials are underway to evaluate the safety and immunogenicity of maternal anti-GBS vaccine candidates.

Epidural analgesia and neonatal short-term outcomes during routine childbirth: a 10-year retrospective analysis from the national birth registry of Austria

BACKGROUND

Epidural analgesia (EA) is well-accepted for pain relief during labor. Still, the impact on neonatal short-term outcome is under continuous debate. This study assessed the outcome of neonates in deliveries with and without EA in a nationwide cohort.

METHODS

We analyzed the National Birth Registry of Austria between 2008 and 2017 of primiparous women with vaginal birth of singleton pregnancies. Neonatal short-term morbidity was assessed by arterial cord pH and base excess (BE). Secondary outcomes were admission to a neonatological intensive care unit, APGAR scores, and perinatal mortality. Propensity score-adjusted regression models were used to investigate the association of EA with short-term neonatal outcome.

RESULTS

Of 247,536 included deliveries, 52 153 received EA (21%). Differences in pH (7.24 vs. 7.25; 97.5% CI -0.0066 to -0.0047) and BE (-5.89±3.2 vs. -6.15±3.2 mmol/L; 97.5% CI 0.32 to 0.40) with EA could be shown. APGAR score at five minutes <7 was more frequent with EA (OR 1.45; 95% CI: 1.29 to 1.63). Admission to a neonatological intensive care unit occurred more often with EA (4.7% vs. 3.4%) with an OR for EA of 1.2 (95% CI: 1.14 to 1.26). EA was not associated with perinatal mortality (OR 1.33; 95% CI: 0.79 to 2.25).

CONCLUSIONS

EA showed no clinically relevant association with neonatal short-term outcome. Higher rates of NICU admission and APGAR score after five minutes <7 were observed with EA. The overall use of EA in Austria is low, and an investigation of causes may be indicated.

Role of mitochondrial DNA level in epidural-related maternal fever: a single-centre, observational, pilot study

INTRODUCTION

Epidural analgesia has been associated with intrapartum maternal fever development. Epidural-related maternal fever (ERMF) is believed to be based on a non-infectious inflammatory reaction. Circulating cell-free mitochondrial deoxyribonucleic acid (mtDNA) is one of the possible triggers of sterile inflammatory processes; however, a connection has not been investigated so far. Therefore, this study aimed to investigate cell-free mtDNA alterations in women in labour with ERMF in comparison with non-febrile women.

MATERIAL AND METHODS

A total of 60 women in labour were assessed for maternal temperature every 4 h and blood samples were obtained at the beginning and after delivery. Depending on the analgesia and the development of fever (axillary temperature ≥ 37.5 °C), the women were allocated either to the group of no epidural analgesia (n = 17), to epidural analgesia no fever (n = 34) or to ERMF (n = 9). Circulating cell-free mtDNA was analysed in the maternal plasma for the primary outcome whereas secondary outcomes include the evaluation of inflammatory cytokine release, as well as placental inflammatory signs.

RESULTS

Of the women with epidural analgesia, 20% (n = 9) developed ERMF and demonstrated a decrease of circulating mtDNA levels during labour (p = 0.04), but a trend towards higher free nuclear DNA. Furthermore, women with maternal pyrexia showed a 1.5 fold increased level of Interleukin-6 during labour. A correlation was found between premature rupture of membranes and ERMF.

CONCLUSIONS

The pilot trial revealed an evident obstetric anaesthesia phenomenon of maternal fever due to epidural analgesia in 20% of women in labour, demonstrating counterregulated free mtDNA and nDNA. Further work is urgently required to understand the connections between the ERMF occurrence and circulating cell-free mtDNA as a potential source of sterile inflammation.

TRIAL REGISTRATION

NCT0405223 on clinicaltrials.gov (registered on 25/07/2019).

Clinical chorioamnionitis at term: definition, pathogenesis, microbiology, diagnosis, and treatment

Clinical chorioamnionitis, the most common infection-related diagnosis in labor and delivery units, is an antecedent of puerperal infection and neonatal sepsis. The condition is suspected when intrapartum fever is associated with two other maternal and fetal signs of local or systemic inflammation (eg, maternal tachycardia, uterine tenderness, maternal leukocytosis, malodorous vaginal discharge or amniotic fluid, and fetal tachycardia). Clinical chorioamnionitis is a syndrome caused by intraamniotic infection, sterile intraamniotic inflammation (inflammation without bacteria), or systemic maternal inflammation induced by epidural analgesia. In cases of uncertainty, a definitive diagnosis can be made by analyzing amniotic fluid with methods to detect bacteria (Gram stain, culture, or microbial nucleic acid) and inflammation (white blood cell count, glucose concentration, interleukin-6, interleukin-8, matrix metalloproteinase-8). The most common microorganisms are Ureaplasma species, and polymicrobial infections occur in 70% of cases. The fetal attack rate is low, and the rate of positive neonatal blood cultures ranges between 0.2% and 4%. Intrapartum antibiotic administration is the standard treatment to reduce neonatal sepsis. Treatment with ampicillin and gentamicin have been recommended by professional societies, although other antibiotic regimens, eg, cephalosporins, have been used. Given the importance of Ureaplasma species as a cause of intraamniotic infection, consideration needs to be given to the administration of antimicrobial agents effective against these microorganisms such as azithromycin or clarithromycin. We have used the combination of ceftriaxone, clarithromycin, and metronidazole, which has been shown to eradicate intraamniotic infection with microbiologic studies. Routine testing of neonates born to affected mothers for genital mycoplasmas could improve the detection of neonatal sepsis. Clinical chorioamnionitis is associated with decreased uterine activity, failure to progress in labor, and postpartum hemorrhage; however, clinical chorioamnionitis by itself is not an indication for cesarean delivery. Oxytocin is often administered for labor augmentation, and it is prudent to have uterotonic agents at hand to manage postpartum hemorrhage. Infants born to mothers with clinical chorioamnionitis near term are at risk for early-onset neonatal sepsis and for long-term disability such as cerebral palsy. A frontier is the noninvasive assessment of amniotic fluid to diagnose intraamniotic inflammation with a transcervical amniotic fluid collector and a rapid bedside test for IL-8 for patients with ruptured membranes. This approach promises to improve diagnostic accuracy and to provide a basis for antimicrobial administration.

Serum Magnesium Level as a Biomarker to Predict the Risk of Labor Epidural Anesthesia Associated Fever

Objective

Excessive pain will have adverse effects on the mother and fetus. Labor epidural analgesia greatly reduces the pain, which is widely carried out abroad. Labor epidural anesthesia-associated fever (LEAF) is the biggest problem for labor epidural anesthesia. This study aimed to evaluate the clinical value of serum magnesium levels to predict the LEAF.

Methods

Overall 528 singleton term-pregnant women who underwent labor epidural anesthesia in Fujian Provincial Maternity and Children's Health Hospital, affiliated hospital of Fujian Medical University from January 2019 to June 2019, were analyzed retrospectively. The serum magnesium level was detected using venous blood samples. The relationship between the serum magnesium level and LEAF was interpreted, and the optimal cut-off values of the serum magnesium level to predict LEAF were calculated.

Results

Overall, 65 (12.30%) participants had LEAF. And a higher rate of the bulging membrane, gestational hypertension, neonatal intensive care unit (NICU) admission, and the different mode of delivery was significantly associated with LEAF. Also, the serum magnesium level demonstrated higher significantly in presence of LEAF than absence (P<0.05). What is more, it indicated that the area under the receiver operating characteristic curve (AUC) for the serum magnesium level was 0.825, and an optimal cut-off of the serum magnesium level was 0.855 mg/dl. Furthermore, it demonstrated that the serum magnesium level had the highest OR (OR= 7.49; 95% CI (4.58-14.35)) (P<0.001). The bulging membrane is an independent risk factor presence of LEAF (OR = 1.55; 95% CI (1.01-2.43)) (P=0.038).

Conclusion

This study demonstrated that the baseline of serum magnesium can provide a suitable biomarker to predict LEAF. It can help to provide a useful target for LEAF treatment and enhance surveillance before fever.

Factors associated with epidural-related maternal fever in low-risk term women: a systematic review

BACKGROUND

The underlying mechanism of epidural-related maternal fever (ERMF) is not fully understood. This systematic review aimed to identify factors associated with ERMF in low-risk, full-term women using neuraxial analgesia.

METHODS

PubMed, Embase, Web of Science, CENTRAL, and Wanfang Data were searched from inception to September 10, 2022 with no language restriction. Studies reported descriptive data regarding the factors associated with ERMF. A random effects model meta-analysis was used to pool the raw data of univariate analyses for each identified factor. Sensitivity and subgroup analyses were performed to explore possible sources of heterogeneity.

RESULTS

Eighteen observational studies involving 33 427 women were included, with 18 factors eligible for meta-analyses. Higher body mass index, baseline temperature, admission maternal interleukin-6 levels and white blood cell counts, nulliparity, increasing gestational age, longer duration of labor and rupture of membranes, increasing number of vaginal examinations, oxytocin use, higher birth weight, lower cervical dilation at initiation of analgesia, and longer analgesia duration were associated with increased risk of ERMF, while intermittent compared with continuous epidural dosing was associated with a decreased risk of ERMF (odds ratio 0.25, 95% CI 0.16 to 0.48, P < 0.001). However, heterogeneity among studies was high and the quality of evidence was low for these meta-analyses, except for intermittent epidural dosing.

CONCLUSIONS

Many factors are associated with ERMF but may not be independent or causal. Further study is needed to clarify the interactions of these factors in ERMF development and whether modification of these factors might influence risk of ERMF.

Effects of neuraxial labor analgesia on intrapartum maternal fever in full-term pregnancy and its influence on birth outcomes

Introduction

This study aimed to explore the relationship between neuraxial labor analgesia and intrapartum fever and to demonstrate the influence of maternal fever on perinatal outcomes within 6 weeks after birth.

Methods

This was a secondary analysis of a multicenter prospective cohort study that enrolled women with single- and full-term cephalic pregnancy in northern China. Intrapartum maternal fever was defined as the highest axillary temperature during labor ≥37.5°C. Data on baseline characteristics, maternal variables, and neonatal outcomes were all collected. The association between neuraxial labor analgesia and intrapartum maternal fever was analyzed with logistic regression models, and the cutoff point was identified by the receiver operating characteristic curve.

Results

Of 577 parturients, 74 (12.8%) developed intrapartum fever. Neuraxial analgesia was associated with an increased risk of maternal intrapartum fever with or without adjusting for confounding factors (adjusted OR = 2.68; 95% CI: 1.32-5.47; p = 0.007). Further analysis showed that neuraxial analgesia of <5 h did not increase the risk of intrapartum fever compared with no analgesia (OR = 1.52; 95% CI: 0.63-3.64; p = 0.35), and longer neuraxial labor analgesia time (over 5 h) significantly increased the risk of fever (OR = 3.38; 95% CI: 1.63-7.01; p = 0.001). Parturients with intrapartum fever suffered more maternal adverse outcomes compared with those without fever (p < 0.001). Neonates of women with intrapartum fever had slightly higher rates of composite adverse neonatal outcomes compared with those without fever; however, the difference was not statistically significant (p = 0.098).

Conclusion

In women with low-risk pregnancies, a longer time of neuraxial labor analgesia was associated with an increased risk of intrapartum maternal fever. Intrapartum fever was related to adverse maternal outcomes but did not significantly affect neonatal outcomes within 6 weeks after delivery.

Intrapartum Maternal Fever and Long-Term Infectious Morbidity of the Offspring

Maternal intrapartum fever can lead to various maternal and neonatal complications and is attributed to various etiologies including infectious and non-infectious processes. In this study, we evaluated whether intrapartum fever affects the offspring's tendency to long-term infectious morbidity. A population-based cohort analysis including deliveries between 1991 and 2021 was conducted. The incidence of hospitalizations of the offspring up to the age of 18 years, due to various infectious conditions, was compared between pregnancies complicated by intrapartum fever and those that were not. A Kaplan-Meier survival curve was used to assess cumulative hospitalization incidence. A Cox proportional hazards model was used to control for confounders. Overall, 538 of the 356,356 included pregnancies were complicated with fever. A higher rate of pediatric hospitalizations due to various infectious conditions was found among the exposed group, which was significant for viral, fungal and ENT infections (p < 0.05 for all). The total number of infectious-related hospitalizations was significantly higher (30.1% vs. 24.1%; OR = 1.36; p = 0.001), as was the cumulative incidence of hospitalizations. This association remained significant after controlling for confounders using a Cox proportional hazards model (adjusted HR = 1.21; 95% CI 1.04-1.41, p = 0.016). To conclude, fever diagnosed close to delivery may influence offspring susceptibility to pediatric infections.

Single versus dual antibiotic regimen in women with term prolonged rupture of membranes and intrapartum fever: a retrospective study

OBJECTIVES

The impact of E. coli in causing peripartum infections has been increasing due to rising ampicillin resistance. In this study, we compared maternal and neonatal outcomes of women with prolonged rupture of membranes (ROM >18h) and intrapartum fever, according to two antibiotic regimens they received, and describe the bacterial distribution focusing on risk factors for Enterobacteriaceae-related infectious morbidity.

STUDY DESIGN

This 10-year retrospective study of women with ROM >18h and intrapartum fever included 62 women who were treated with ampicillin and gentamicin due to suspected intraamniotic infection and 79 without these signs who were treated with ampicillin alone. The primary outcomes were endometritis and neonatal early-onset sepsis (EOS) rates. Outcomes were compared using univariate and multivariate analyses.

RESULTS

Among women who received ampicillin alone compared with dual therapy, rates were higher of endometritis (17% vs. 3%, p<0.001), neonatal early onset sepsis (7.5% vs. 0%, p=0.03), Enterobacteriaceae positive placental swab culture (67.9% vs. 15.7%, p<0.001), and histopathological subchorionitis (25.3% vs. 8.0%, p=0.008). Over 83% of Enterobacteriaceae isolates were ampicillin-resistant. Gestational age at delivery >41 weeks, meconium at delivery, ROM >24h and treatment with a single antibiotic agent were associated with the presence of a positive Enterobacteriaceae placental swab culture.

CONCLUSION

Ampicillin compared to dual treatment in women with prolonged ROM and fever might promote the growth of ampicillin-resistant Enterobacteriaceae (including E.coli) and increase risks of maternal and neonatal infectious morbidity.

Association between combined spinal-epidural analgesia and neurodevelopment at 3 years old: The Japan Environment and Children's Study

AIM

To investigate the association between maternal combined spinal-epidural analgesia during vaginal delivery and neurodevelopment in 3-year-old children.

METHODS

Using data from the Japan Environment and Children's Study, a birth cohort study on pregnant women and their offspring, we described the background, perinatal outcomes, and neurodevelopmental outcomes of participants with a singleton pregnancy who received combined spinal-epidural analgesia during vaginal delivery and those who did not. The association between maternal combined spinal-epidural analgesia and abnormalities in five domains of the Ages and Stages Questionnaire, Third Edition, was analyzed using univariable and multivariable logistic regression analyses. Crude and adjusted odds ratios with 95% confidence intervals (95% CI) were calculated.

RESULTS

Among 59 379 participants, 82 (0.1%) children (exposed group) were born to mothers who received combined spinal-epidural analgesia during vaginal delivery. In the exposed versus control groups, 1.2% versus 3.7% had communication abnormalities (adjusted odds ratio [95% CI]: 0.30 [0.04-2.19]), 6.1% versus 4.1% exhibited gross-motor abnormalities (1.36 [95% CI: 0.55-3.36]), 10.9% vs. 7.1% had fine-motor abnormalities (1.46 [95% CI: 0.72-2.96]), 6.1% vs. 6.9% showed difficulties with problem-solving (0.81 [95% CI: 0.33-2.01]), and 2.4% vs. 3.0% had personal-social problems (0.70 [95% CI: 0.17-2.85]).

CONCLUSIONS

Exposure to combined spinal-epidural analgesia during vaginal delivery was not associated with the risk of neurodevelopmental abnormalities; however, the sample size of our study might not be appropriate for the study design.

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.

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.

Association of epidural analgesia during labor with neurodevelopment of children during the first three years: the Japan Environment and Children's Study

BACKGROUND

Epidural analgesia relives pain during labor. However, the long-term effects on neurodevelopment in children remain unclear. We explored associations between exposure to epidural analgesia during labor and childhood neurodevelopment during the first 3 years of life, in the Japan Environment and Children's Study (JECS), a large-scale birth cohort study.

METHODS

Pregnant women were recruited between January 2011 and March 2014, and 100,304 live births of singleton children born at full-term by vaginal delivery, and without congenital diseases were analyzed. Data on mothers and children were collected using a self-administered questionnaires and medical record transcripts. The children's neurodevelopment was repeatedly assessed for five domains (communication, gross motor, fine motor, problem solving, and personal-social), using the Ages and Stages Questionnaires, Third Edition, at six time points from age 6 to 36 months. After adjusting for potential confounders, the associations between exposure to epidural analgesia during labor and children's neurodevelopment at each time point were assessed.

RESULTS

Of the 42,172 children with valid data at all six time points, 938 (2.4%) were born to mothers who received epidural analgesia during labor. Maternal exposure to epidural analgesia was associated with neurodevelopmental delays during the first 3 years after birth. Delay risks in gross and fine motor domains were the greatest at 18 months (adjusted odds ratio (aOR) [95% confidence interval (CI)]: 1.40 [1.06, 1.84] and 1.54 [1.17, 2.03], respectively), subsequently decreasing. Delay risks in communication and problem-solving domains were significantly high at 6 and 24 months, and remained significant at 36 months (aOR [95% CI]: 1.40 [1.04, 1.90] and 1.28 [1.01, 1.61], respectively). Exposure to epidural analgesia was also associated with the incidence of problem solving and personal-social delays from 18 to 24 months old. Neurodevelopmental delay risks, except for communication, were dominant in children born to mothers aged ≥30 years at delivery.

CONCLUSIONS

This study showed that maternal exposure to epidural analgesia during labor was associated with neurodevelopmental delays in children during the first 3 years after birth.

Delivery, maternal and neonatal outcomes in nulliparous women with gestational diabetes undergoing epidural labour analgesia: a propensity score-matched analysis

OBJECTIVE

This study aimed to retrospectively analyse the influence of epidural labour analgesia (ELA) on delivery and maternal and neonatal outcomes in nulliparous women with gestational diabetes mellitus (GDM) using propensity score-matched analysis.

DESIGN

Retrospective cohort analysis.

SETTING

Primary care practices in a teaching hospital from March 2018 to October 2021.

PARTICIPANTS

A total of 816 delivery records of nulliparous women with GDM were collected and retrospectively analysed.

INTERVENTIONS

ELA and non-ELA (NELA) cohorts were assessed.

MAIN OUTCOME MEASURE

The primary outcome assessed was delivery type (spontaneous, assisted vaginal or caesarean). The secondary outcomes assessed included labour duration and maternal and neonatal outcomes.

RESULTS

A total of 137 propensity score-matched pairs of ELA and NELA patients were analysed. ELA was associated with a decreased rate of caesarean section (18.3% vs 46.0% in the ELA vs NELA cohort, respectively; p<0.05) and an increased occurrence of assisted vaginal delivery (35.8% vs 12.4% in the ELA vs NELA cohort, respectively; p<0.05). The duration of the first and total stages of labour was prolonged, the occurrence of postpartum fever increased, and the duration of hospital stay was shortened in those receiving ELA (all p<0.05). Additionally, neonatal birth weight, plasma glucose levels and neonatal macrosomia occurrence increased, while neonatal intensive care unit admissions and neonatal hypoglycaemia decreased in the ELA versus the NELA group (all p<0.05). With respect to other maternal and neonatal outcomes, both cohorts were similar.

CONCLUSIONS

The use of ELA decreases the rate of caesarean section and improves maternal and neonatal outcomes in nulliparous women with GDM.

TRIAL REGISTRATION NUMBER

ChiCTR-2000033091.

Risk factors of maternal intrapartum fever and the effect of fever duration on neonatal morbidity in different temperature

AIM

To investigate the clinical risk factors of intrapartum fever and explore the relationship between fever duration and neonatal morbidity of different fever peak.

METHODS

A case-control study was conducted, and 714 pregnant women were divided into fever and nonfever group. Multivariable logistic regression model was estimated to evaluate the risk factors for maternal intrapartum fever. Receiver operating characteristic curve was adopted to explore the relationship between fever duration and fetal distress of different fever peak to find the cut-off point, then the neonatal outcomes of women with fever ≥38°C in two groups of different fever duration were compared.

RESULTS

Epidural analgesia (odds ratio [OR]: 6.89, p < 0.001), longer time of membrane rupture (OR: 1.06, p < 0.001) and longer time of first stage of labor (OR: 1.04, p = 0.03) were considered as independent risk factors for maternal fever. For women with temperature <38°C, fever duration was not associated with fetal distress, whereas the women with temperature ≥38°C, fever duration longer than 93.5 min was a good predictor of fetal distress (Area under curve (AUC) = 0.82, p < 0.05). Further analysis showed that infants of women with fever peak ≥38°C and fever duration longer than 90 min had a higher rate of 1 min Apgar score <7 (15.5% vs. 2.2%, p = 0.03), assisted ventilation (29.6% vs. 11.1%, p = 0.02), and admission to neonatal ward (87.3% vs. 60.0%, p = 0.001).

CONCLUSIONS

Epidural analgesia, longer time of membrane rupture, and longer time of first stage of labor were considered as independent risk factors for maternal intrapartum fever. For women with fever ≥38°C, controlling fever time less than 90 min might be helpful to reduce neonatal morbidity.

Chorioamnionitis and its association with neonatal and maternal adverse outcomes in women with and without epidural analgesia administration

OBJECTIVE

To evaluate neonatal fever and adverse maternal and neonatal outcomes in febrile laboring women and assess whether the time interval between epidural analgesia (EA) administration and chorioamnionitis is associated with these complications.

METHODS

A retrospective cohort study at a university affiliated medical center between 2003 and 2015. Included were women who underwent term vaginal delivery attempt and diagnosed with chorioamnionitis. The primary outcomes compared between febrile women with and without EA were neonatal fever and adverse neonatal and maternal outcomes. The association between time from EA to fever (<6, 6-12, >12 h) and maternal and neonatal complications was also assessed.

RESULTS

During the study period, 1,933 women with chorioamnionitis were assessed. Of them, 1,810 (93.6%) received EA prior to fever and 123 (6.4%) febrile parturients did not receive EA. Neonatal fever and other neonatal adverse outcomes were similar in the EA vs. non-EA group (2.2% vs. 0.8% and 2.7% vs. 4.9% (NS)), except for transient tachypnea of the newborn rates which were lower in the EA group (1.4% vs. 4.1%, p = 0.043). Maternal complications were similar, besides for higher rates of instrumental deliveries found in the EA group (24.0% vs. 5.7%, p < 0.001). Time between EA and fever onset was not associated with neonatal complications in logistic regression analysis.

CONCLUSION

Neonatal and maternal outcomes are similar in febrile laboring women with and without EA. The time interval between EA and onset of fever is not associated with increased rates of neonatal fever or adverse outcomes and should not affect the management of labor.

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.

Suspected clinical chorioamnionitis with peak intrapartum temperature <380C: the prevalence of confirmed chorioamnionitis and short term neonatal outcome

Background

Chorioamnionitis (CA) affects up to 3.9% of all deliveries worldwide and is one of the leading causes of early-onset neonatal sepsis. Fever≥38⁰C is an essential criterion for the diagnosis of clinical CA. Obstetricians frequently take the maternal risk factors into consideration, and many mothers are treated as CA even with peak intrapartum temperature (PIT) between 37.6⁰C to 37.9⁰C if they have other clinical signs and risk factors.

Aim

To estimate the prevalence of confirmed chorioamnionitis and adverse neonatal outcomes among those mothers with PIT below 38⁰C.

Materials and methods

Retrospective chart review among mothers delivered at Al-Wakra Hospital, Qatar, between1^stJanuary2016 to 31^stDecember 2019 with a clinical suspicion of CA.

Results

Among 21,471 mothers, 442 were suspected of having CA (2.06%, 95% CI 1.88 to 2.26%). After exclusions, 415 were included in the study, 203(48.9%) mothers had PIT between 37.6-37.9⁰C. There was no significant difference in the rate of confirmed CA between the low (<38⁰C) and higher (≥38⁰C) temperature groups (25.4%Vs.31.3%, OR0.75, 95%CI0.46-1.25 , p.262). More patients in the low-temperature group received paracetamol for PIT between 37.6 to 37.9 ⁰C, while it was less frequently used for such milder elevation in higher temperature group (88.2%Vs.38.9%, OR11.69, 95% CI 6.46-2.15, p <.001).

Conclusion

The incidence of suspected clinical CA in our institution was within the international rates. Although nearly half of the mothers with suspected clinical CA had peak temperature below the recommended diagnostic criteria, the rate of confirmed CA and neonatal outcome was not significantly different from those with PIT≥38⁰C. Early antipyretic use might have affected further elevation of temperature.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03239-9.

Epidural analgesia in labor: A narrative review

Lumbar epidural is the most effective form of pain relief in labor with around 30% of laboring women in the UK and 60% in the USA receiving epidural analgesia. Associations of epidural on maternal, obstetric, and neonatal outcomes have been the subject of intense study, though a number of uncertainties persist. The present narrative review explores important areas of research surrounding epidural analgesia in obstetric patients including methods of initiation and administration, choice of local anesthetic solution, and the addition of adjuvants. Key meta-analyses exploring associations of epidural analgesia on maternal and neonatal outcomes are identified and summarized.

Outcomes associated with antibiotic administration for isolated maternal fever in labor

BACKGROUND

The American College of Obstetricians and Gynecologists currently recommends that antibiotic treatment should be considered for women with isolated maternal fevers during labor. However, there is little known about the maternal and neonatal impact of antibiotic treatment in this scenario.

OBJECTIVE

We sought to assess the outcomes in women with a nonsustained, isolated maternal fever treated with antibiotics and compare it with expectant management.

STUDY DESIGN

This was a retrospective cohort study of laboring women with a singleton gestation at term and a single temperature of between 38.0°C and 38.9°C without other evidence of infection (leukocytosis >15,000/mm³, fetal tachycardia, malodorous amniotic fluid, suspected alternate source of infection) at a tertiary teaching hospital. A contemporaneously maintained, validated obstetrical database was used to identify women for our cohort. Women with rheumatologic or renal disease, nongestational diabetes, preterm labor, placental abruption, vaginal bleeding, HIV, malpresentation, and fetal anomalies were excluded. The primary outcome was a postpartum fever above 38.0°C. Secondary maternal outcomes were treatment for postpartum endometritis, uterine atony, postpartum hemorrhage, admission to the intensive care unit, and postpartum length of stay. Secondary neonatal outcomes were neonatal intensive care unit admission, 5-minute Apgar score of <7, 5-minute Apgar score of <4, neonatal intensive care unit length of stay, and neonatal antibiotic administration. The results were compared using univariable and multivariable analyses.

RESULTS

From January 1, 2015, to December 31, 2018, 359 women were identified; 85 received antibiotics and 274 did not. The baseline characteristics were similar between the groups, except for gestational age at the time of delivery (39.2 weeks vs 39.5 weeks for the antibiotic and no antibiotic groups, respectively; P=.02). The incidence in postpartum fever showed a downward trend in the antibiotic group (10.59% for the antibiotic group vs 18.98% for the no antibiotic group; P=.07). Significantly fewer women in the antibiotic group were treated for postpartum endometritis (3.53% vs 11.31%; P=.03). Neonatal intensive care unit admission and neonatal antibiotic administration rates were higher in the antibiotic group (41.18% vs 17.88%; P<.001 and 36.47% vs 12.41%; P<.001, respectively). The incidence of 5-minute Apgar score of <7 was higher in the antibiotic group (8.25% vs 2.19%; P=.016). After controlling for age, gestational age, body mass index, group B streptococci status, delivery method, parity, administration of epidural, and receipt of acetaminophen, the odds for postpartum fever were reduced by a factor of 0.42 (95% confidence interval, 0.18-0.99) among women who received antibiotics when compared with those who did not receive antibiotics. Outcome results are presented in Table 2.

CONCLUSION

Although there was a lower rate of treatment for endometritis among women who received antibiotics for a single isolated maternal fever, there was a higher rate of neonatal intensive care unit admissions and 5-minute Apgar score of <7. This indicates that there likely is maternal benefit associated with antibiotic use, however, there are concerns about the neonatal risk.

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.

Evaluation of Epidural Analgesia Use During Labor and Infection in Full-term Neonates Delivered Vaginally

IMPORTANCE

Quantification of potential consequences associated with the use of epidural analgesia during labor could help to improve the safety and quality of labor and delivery care for parturient women.

OBJECTIVE

To evaluate the association between epidural analgesia use during labor and neonatal infection in a large cohort of parturient women.

DESIGN, SETTING, AND PARTICIPANTS

This propensity score-matched cohort study was conducted at a university-affiliated hospital in Shanghai, China. Women at full-term pregnancy undergoing vaginal delivery between January 2013 and October 2018 were included in the study. Parturient women who were parous, experiencing premature delivery (gestational age <37 weeks), were pregnant with more than 1 fetus, or had experienced a stillbirth were excluded. Data were analyzed from October 2019 to June 2020.

EXPOSURES

The use of epidural analgesia during labor.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of neonatal infection, including neonatal sepsis, neonatal uncharacterized infection, neonatal pneumonia, and neonatal necrotizing enterocolitis reported in the medical record. Secondary outcomes included the incidence of maternal intrapartum fever and histologic chorioamnionitis.

RESULTS

Among 37 786 parturient women included (mean [SD] age, 29.5 [3.0] years), 19 968 (52.8%) received epidural analgesia during labor. In the propensity score-matched cohort (including 15 401 parturient women in each group), use of epidural analgesia was associated with a higher incidence of neonatal infection (absolute risk difference, 2.6%, 95% CI, 2.2%-3.0%; relative risk [RR], 2.43; 95% CI, 2.11-2.78), including higher incidence of sepsis (absolute risk difference, 0.1%, 95% CI, 0.1%-0.2%; RR, 3.50; 95% CI, 1.73-7.07) and uncharacterized infection (absolute risk difference, 2.2%, 95% CI, 1.9% to 2.6%; RR, 2.69; 95% CI, 2.30-3.15), compared with no epidural analgesia use. Use of epidural analgesia was also associated with greater incidence of maternal intrapartum fever (RR, 4.12; 95% CI, 3.78-4.50) and histologic chorioamnionitis (RR, 4.08; 95% CI, 3.59-4.64) compared with no epidural analgesia use.

CONCLUSIONS AND RELEVANCE

This cohort study found that use of epidural analgesia in full-term nulliparous women undergoing vaginal delivery was associated with an increased risk of neonatal infection, pending further investigation. These findings support efforts to further improve safety and quality of labor and delivery care for parturient women.

Epidural Dexmedetomidine for Prevention of Intrapartum Fever During Labor Analgesia: A Randomized Controlled Trial

INTRODUCTION

Intrapartum fever occurs frequently during labor. The purpose of this study was to investigate the effects of epidural dexmedetomidine on maternal temperature, pain score and adverse effects during labor analgesia.

METHODS

A total of 600 full-term primiparous parturients were randomly divided into two groups. The dexmedetomidine group (Group Dex, n = 300) received 0.1% ropivacaine with 0.5 µg/mL dexmedetomidine for epidural analgesia during labor, while the control group (Group C, n = 300) received 0.1% ropivacaine alone. The maternal temperature, visual analogue scale (VAS) and Ramsay sedation score (RSS) were recorded, and the systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were monitored. Side effects, if any, were also recorded.

RESULTS

The incidence of intrapartum fever was lower in Group Dex than in Group C (4.1% vs. 8.7%, χ2 = 5.07, P = 0.024). VAS values from the time of 3 cm cervical dilatation to 10 cm cervical dilatation were also lower in Group Dex than in Group C (1.0 ± 0.9 vs. 1.3 ± 0.7, t = 3.62, P < 0.001; 2.8 ± 0.8 vs. 3.3 ± 0.8, t = 8.09, P < 0.001; 3.1 ± 0.9 vs. 3.3 ± 0.8, t = 3.88, P < 0.001; 3.6 ± 0.8 vs. 4.1 ± 1.0, t = 5.86, P < 0.001, respectively). HR from the time of 3 cm cervical dilatation to 10 cm cervical dilatation was lower during labor in Group Dex than in Group C (80.0 ± 4.3 vs. 83.1 ± 5.4 beats/min, t = 7.58, P < 0.001; 81.1 ± 4.0 vs. 83.7 ± 5.5 beats/min, t = 6.48, P < 0.001; 78.9 ± 5.4 vs. 81.5 ± 6.3 beats/min, t = 5.41, P < 0.001; 83.1 ± 5.3 vs. 84.8 ± 5.6 beats/min, t = 3.75, P < 0.001, respectively), while SBP and DBP were similar between the two groups. The incidence of adverse events during labor was also similar between the two groups.

CONCLUSION

The present study showed that dexmedetomidine could reduce the incidence of intrapartum fever and relieve pain during labor without increasing adverse events.

TRIAL REGISTRATION

ChiCTR-OPC-16008548.

Potential impact of epidural labor analgesia on the outcomes of neonates and children

This review summarizes recent evidences regarding the potential influences of epidural labor analgesia (ELA) on the outcomes of neonates and children. Terms and relevant words including “ELA,” “ELA and neonatal outcomes,” “ELA and children's development,” and “ELA and children's neurocognitive development” were used to search articles published in PubMed database up to October 2019. Original articles and reviews regarding potential influences of ELA on neonates and children were identified. Relevant references of the selected articles were also screened. The anesthetics used during ELA can be absorbed, enter the fetus, and produce neonatal depression; however, these effects are less severe than those during systematic opioid analgesia. The impact of anesthetic exposure during ELA on children's neurodevelopment has not been fully studied, but would be mild if any. ELA increases the risk of intrapartum maternal fever; the latter may be harmful to neonatal outcomes. The use of ELA may increase birth injury by increasing instrumental delivery, although long-term adverse events are rare. On the other hand, ELA may reduce maternal depression and, thus, produce favorable effects on neurocognitive development in childhood; but evidences are still lacking in this aspect. ELA may produce both favorable and unfavorable effects on neonates and children. These effects should be discussed with parturient women before making decisions. The potential harmful effects should be carefully managed. The overall impacts of ELA on neonatal and children's outcomes need to be studied further.

The impact of peak and duration of maternal intrapartum fever on perinatal outcomes

BACKGROUND

Intrapartum fever is a common perinatal complication, associated with short- and long-term adverse outcomes. Limited data exist regarding the association between the peak and duration of maternal fever and the extent and severity of maternal and neonatal complications.

OBJECTIVE

This study aimed to examine the association between maternal intrapartum fever peak and duration and perinatal outcomes.

STUDY DESIGN

A retrospective cohort analysis of term singleton live births in 2 medical centers between the years 2003 and 2015 was conducted. The study group included parturients who experienced intrapartum fever, defined as a temperature of ≥38.0°C (100.4°F). Fever duration was defined as the time elapsed between the first documented fever and subsequent first documented normal body temperature (<38°C or <100.4°F) or if the temperature did not return to normal until delivery. Adjusted risks for adverse perinatal outcomes were calculated using multiple logistic regression models to control for confounders.

RESULTS

A cohort study of 85,713 deliveries was analyzed, of which 1517 (1.8%) parturients experienced fever during delivery. Adverse composite neonatal outcome gradually worsens, in a dose-response manner, with higher maximal maternal temperature. Similar dose-response deterioration was found when maximal parturient temperature was combined with fever duration (P=.015). Higher or longer maternal fever was not independently associated with cesarean or instrumental deliveries (P=.648). Duration alone was not significantly associated with worsening neonatal outcomes (P=.711).

CONCLUSION

Maximal intrapartum maternal fever, solely and when combined with fever duration, is correlated with neonatal complications in a dose-dependent manner. Further prospective studies are needed to examine the potential benefit of rigorous maternal body temperature control on perinatal outcomes.

Risk of Neonatal Short-Term Adverse Outcomes Associated with Noninfectious Intrapartum Hyperthermia: A Nested Case-Control Retrospective Study

OBJECTIVE

This study aimed to identify risk factors for adverse neonatal outcomes in neonates born to mothers with noninfectious intrapartum hyperthermia.

STUDY DESIGN

A retrospective study was conducted of 460 singleton deliveries diagnosed with noninfectious intrapartum hyperthermia. Logistic regression was used to estimate the association between ante- and intrapartum risk factors and neonatal outcomes.

RESULTS

The 460 singleton pregnant women were 19 to 43 years of age. They developed an intrapartum temperature of ≥37.5°C somewhere between 34^0/7 to 41^4/7 weeks' gestation; 437 (95%) were nulliparous. Meconium-stained amniotic fluid was associated with positive pressure ventilation or intubation ventilation (odds ratio [OR] = 5.940, 95% confidence interval [CI]: 2.038-17.318), birth depression (OR = 6.288, 95% CI: 2.273-17.399), and wet lung (OR = 2.747, 95% CI: 1.322-5.709). Induction of labor with artificial rupture of membranes (AROM; OR = 2.632, 95% CI: 1.325-5.228) was associated with neonatal infections. Maternal temperature ≥ 38°C was associated with neonate's artery blood gas pH < 7.3 (OR = 2.366, 95%CI: 1.067-5.246) and wet lung (OR = 2.909, 95% CI: 1.515-5.586). Maternal elevated C-reactive protein (CRP) was associated with neonatal infections (OR = 1.993, 95% CI: 1.260-3.154) and wet lung (OR = 2.600, 95% CI: 1.306-5.178).

CONCLUSION

Meconium-stained amniotic fluid, induction of labor, maternal temperature ≥ 38°C, and elevated CRP during labor were risk factors for adverse neonatal outcomes.

Clinical chorioamnionitis at term X: microbiology, clinical signs, placental pathology, and neonatal bacteremia - implications for clinical care

OBJECTIVES

Clinical chorioamnionitis at term is considered the most common infection-related diagnosis in labor and delivery units worldwide. The syndrome affects 5-12% of all term pregnancies and is a leading cause of maternal morbidity and mortality as well as neonatal death and sepsis. The objectives of this study were to determine the (1) amniotic fluid microbiology using cultivation and molecular microbiologic techniques; (2) diagnostic accuracy of the clinical criteria used to identify patients with intra-amniotic infection; (3) relationship between acute inflammatory lesions of the placenta (maternal and fetal inflammatory responses) and amniotic fluid microbiology and inflammatory markers; and (4) frequency of neonatal bacteremia.

METHODS

This retrospective cross-sectional study included 43 women with the diagnosis of clinical chorioamnionitis at term. The presence of microorganisms in the amniotic cavity was determined through the analysis of amniotic fluid samples by cultivation for aerobes, anaerobes, and genital mycoplasmas. A broad-range polymerase chain reaction coupled with electrospray ionization mass spectrometry was also used to detect bacteria, select viruses, and fungi. Intra-amniotic inflammation was defined as an elevated amniotic fluid interleukin-6 (IL-6) concentration ≥2.6 ng/mL.

RESULTS

(1) Intra-amniotic infection (defined as the combination of microorganisms detected in amniotic fluid and an elevated IL-6 concentration) was present in 63% (27/43) of cases; (2) the most common microorganisms found in the amniotic fluid samples were Ureaplasma species, followed by Gardnerella vaginalis; (3) sterile intra-amniotic inflammation (elevated IL-6 in amniotic fluid but without detectable microorganisms) was present in 5% (2/43) of cases; (4) 26% of patients with the diagnosis of clinical chorioamnionitis had no evidence of intra-amniotic infection or intra-amniotic inflammation; (5) intra-amniotic infection was more common when the membranes were ruptured than when they were intact (78% [21/27] vs. 38% [6/16]; p=0.01); (6) the traditional criteria for the diagnosis of clinical chorioamnionitis had poor diagnostic performance in identifying proven intra-amniotic infection (overall accuracy, 40-58%); (7) neonatal bacteremia was diagnosed in 4.9% (2/41) of cases; and (8) a fetal inflammatory response defined as the presence of severe acute funisitis was observed in 33% (9/27) of cases.

CONCLUSIONS

Clinical chorioamnionitis at term, a syndrome that can result from intra-amniotic infection, was diagnosed in approximately 63% of cases and sterile intra-amniotic inflammation in 5% of cases. However, a substantial number of patients had no evidence of intra-amniotic infection or intra-amniotic inflammation. Evidence of the fetal inflammatory response syndrome was frequently present, but microorganisms were detected in only 4.9% of cases based on cultures of aerobic and anaerobic bacteria in neonatal blood.

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.

Maternal temperature in emergency caesarean section (MATES): an observational multicentre study

BACKGROUND

Temperature regulation in women undergoing emergency caesarean section is a complex topic about which there is a paucity of evidence-based recommendations. The adverse effects of inadvertent peri-operative hypothermia are well described. Hyperthermia is also associated with adverse neonatal outcomes, an increased risk of obstetric intervention and increased treatment for suspected sepsis. We conducted a multi-centre observational cohort study to identify the prevalence of hypothermia and hyperthermia during emergency caesarean section. S: Participants undergoing emergency caesarean section were recruited across 14 sites in the UK. The primary end point was maternal temperature in the recovery room. Temperature was measured using a zero heat-flux temperature monitoring device.

RESULTS

Two hundred and sixty-five participants were recruited over a 12-month period. The prevalence of hypothermia (<36.0°C) was 10.7% and the prevalence of hyperthermia (>37.5°C) was 14.7% on admission to recovery. The prevalence of hypothermia, normothermia, and hyperthermia differed among type of anaesthesia: 71.4% of the hypothermic group had received a spinal anaesthetic whereas 76.9% of the hyperthermic group had received epidural top-up anaesthesia. There was a significant decrease in maternal temperature between the time of delivery and admission to the recovery room of 0.20°C (95% CI 0.15 to 0.25, P<0.001).

CONCLUSIONS

Both hypothermia and hyperthermia are prevalent findings in mothers who undergo emergency caesarean section. Therefore, accurate temperature measurement is essential to ensure that an appropriate intra-operative temperature management strategy is employed.

The relationship between epidural analgesia and intrapartum maternal fever and the consequences for maternal and neonatal outcomes: a prospective observational study

AIM

To use continuous real-time monitoring of maternal core body temperature during labor and investigate the association between epidural analgesia, intrapartum maternal fever, and maternal and neonatal outcomes.

METHODS

Among 201 pregnant women attending our institution for a vaginal in-hospital delivery, 159 women received epidural analgesia and 42 women did not receive epidural analgesia. Women's core body temperature was continuously monitored for the duration of labor using a smartphone/iPad-connected wireless thermometer positioned in an axilla. The primary outcome was a change in maternal core body temperature during labor. Among women receiving epidural analgesia, maternal and neonatal outcomes were compared in women who developed an intrapartum fever and those who had no intrapartum temperature elevation.

RESULTS

Of the women receiving epidural analgesia, 26.4% (n = 42/159) developed intrapartum fever ≥38 °C compared to 7.1% (n = 3/42) of women not receiving epidural analgesia. Among those receiving epidural analgesia, women who developed intrapartum fever had a significantly longer first stage of labor and a higher incidence of cesarean section, assisted vaginal delivery, intrapartum hemorrhage, and turbid amniotic fluid compared to women with no intrapartum temperature elevation. Neonates of women who developed intrapartum fever had lower 1- and 5-min Apgar scores compared to neonates of women with no intrapartum temperature elevation; however, the difference was not significant.

CONCLUSION

This study used a precise and accurate method to monitor core body temperature among women receiving epidural analgesia. Results showed that the use of epidural analgesia during labor was associated with intrapartum maternal fever in all stages of labor. Fever after epidural analgesia was associated with adverse maternal outcomes, independent of neonatal complications.

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.

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.

Management of clinical chorioamnionitis: an evidence-based approach

This review aimed to examine the existing evidence about interventions proposed for the treatment of clinical chorioamnionitis, with the goal of developing an evidence-based contemporary approach for the management of this condition. Most trials that assessed the use of antibiotics in clinical chorioamnionitis included patients with a gestational age of ≥34 weeks and in labor. The first-line antimicrobial regimen for the treatment of clinical chorioamnionitis is ampicillin combined with gentamicin, which should be initiated during the intrapartum period. In the event of a cesarean delivery, patients should receive clindamycin at the time of umbilical cord clamping. The administration of additional antibiotic therapy does not appear to be necessary after vaginal or cesarean delivery. However, if postdelivery antibiotics are prescribed, there is support for the administration of an additional dose. Patients can receive antipyretic agents, mainly acetaminophen, even though there is no clear evidence of their benefits. Current evidence suggests that the administration of antenatal corticosteroids for fetal lung maturation and of magnesium sulfate for fetal neuroprotection to patients with clinical chorioamnionitis between 24 0/7 and 33 6/7 weeks of gestation, and possibly between 23 0/7 and 23 6/7 weeks of gestation, has an overall beneficial effect on the infant. However, delivery should not be delayed to complete the full course of corticosteroids and magnesium sulfate. Once the diagnosis of clinical chorioamnionitis has been established, delivery should be considered, regardless of the gestational age. Vaginal delivery is the safer option and cesarean delivery should be reserved for standard obstetrical indications. The time interval between the diagnosis of clinical chorioamnionitis and delivery is not related to most adverse maternal and neonatal outcomes. Patients may require a higher dose of oxytocin to achieve adequate uterine activity or greater uterine activity to effect a given change in cervical dilation. The benefit of using continuous electronic fetal heart rate monitoring in these patients is unclear. We identified the following promising interventions for the management of clinical chorioamnionitis: (1) an antibiotic regimen including ceftriaxone, clarithromycin, and metronidazole that provides coverage against the most commonly identified microorganisms in patients with clinical chorioamnionitis; (2) vaginal cleansing with antiseptic solutions before cesarean delivery with the aim of decreasing the risk of endometritis and, possibly, postoperative wound infection; and (3) antenatal administration of N-acetylcysteine, an antioxidant and antiinflammatory agent, to reduce neonatal morbidity and mortality. Well-powered randomized controlled trials are needed to assess these interventions in patients with clinical chorioamnionitis.

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.

Impact of temperature change from admission to day one on neonatal mortality in a low-resource setting

Background

Thermal control after birth is an essential part of neonatal care. However, the relationship between neonatal temperature at and after admission is unknown. This study aimed to evaluate the change between neonatal temperature at admission and at day 1, and its impact on mortality.

Methods

Retrospective observational study at the Beira Central Hospital, Mozambique. Axillary temperatures were recorded at admission and at day 1 in 1,226 neonates who were admitted to the Special Care Unit between January 1 and December 31, 2017. The relationship between mortality rate and temperature change was evaluated with a matrix plot and a forest plot (obtained from a logistic regression model as odds ratios with 95% confidence intervals).

Results

Normothermia was found in 415 neonates (33.8%) at admission and in 638 neonates (52.0%) at day 1. Mortality rate was highest in (i) neonates who remained in severe/moderate hypothermia (74%), (ii) neonates who rewarmed from hypothermia (40–55%), and (iii) neonates who chilled to severe/moderate hypothermia (38–43%). Multivariable analysis confirmed that temperature change from admission to day 1 was an independent predictor of mortality (p < 0.0001).

Conclusions

In a low-resource setting, one out of three neonates was found hypothermic at day 1 irrespectively of admission temperature. Relevant thermal deviations occurred in a high proportion of newborns with normothermia at admission. Being cold at admission and becoming cold or hyperthermic at day 1 were associated with increased likelihood of mortality. Appropriate actions to prevent both hypothermia and hyperthermia represent both a challenge and a priority during postnatal period.

Survival Status and Predictors of Mortality among Newborns Admitted with Neonatal Sepsis at Public Hospitals in Ethiopia

BACKGROUND

One-fourth of neonatal death is due to neonatal sepsis and nearly 98% of these deaths are occurring at low- and middle-income countries. In Ethiopia, forty percent of under-five mortality occurs during the neonatal period, of which neonatal sepsis accounts for 30-35% of neonatal deaths next to prematurity and its complications. On the other side, among the survived neonates with neonatal sepsis, there exist as vulnerable to short and long-term neurological and developmental morbidity impacting the overall productivity of the child as adult.

METHODS

A longitudinal prospective cohort study was conducted among selected 289 neonates with neonatal sepsis who were admitted in the neonatal intensive care unit at public hospitals in Ethiopia from 1st March 2018 to 31st December 2019. Data were entered into Epi data version 3.02 and exported to SPSS V 25 for analysis. The Kaplan-Meier survival curve together with log-rank test was used to estimate the survival time of the neonates. Variables which had p value < 0.05 in multivariable analysis using the cox proportional hazard model were declared as statistically significant predictors of mortality.

RESULTS

The study was conducted with a total of 289 neonates admitted with neonatal sepsis. The cumulative proportion of surviving at the end of the fourth day was 99.5%, and it was 98.2% at the end of the fifth day. In addition, it was 96.6%, 93.5%, and 91.1% at the end of the sixth, seventh, and eighth day, respectively. The incidence of mortality was 8.65 per 100 neonates admitted with neonatal sepsis. Having a history of intrapartum fever (AHR: 14.5; 95% CI: 4.25, 49.5), history of chorioamnionitis (AHR: 5.7; 95% CI: 2.29, 13.98), induced labor (AHR: 7; 95% CI: 2.32, 21.08), and not initiating exclusive breastfeeding within one hour (AHR: 3.4; 95% CI: 1.34, 12.63) were the independent predictors of mortality.

CONCLUSION

The survival status of neonates among neonates admitted with neonatal sepsis was high at the early admission days and high cumulative proportion of death as the admission period increased. The risk of mortality was high among the neonates with early onset of neonatal sepsis as compared with late onset of neonatal sepsis and history of intrapartum fever, history of diagnosed chorioamnionitis, onset of labor, and EBF initiation within one hour were the independent predictors of mortality among neonates admitted with neonatal sepsis.

Determinants of adverse neonatal outcome in vaginal deliveries complicated by suspected intraamniotic infection

PURPOSE

Intraamniotic infection, categorized into isolated maternal fever, suspected intraamniotic infection (SII), and confirmed intraamniotic infection, is associated with neonatal morbidity. However, there is paucity of data regarding the association between intraamniotic infection duration and neonatal outcomes among term singleton vaginal deliveries. We aimed to study the risk factors for adverse neonatal outcome among vaginal deliveries complicated by SII.

METHODS

A retrospective observational study conducted at a tertiary medical center. All consecutive singleton term deliveries with SII were included between 2011 and 2019. Maternal and obstetrical characteristics were evaluated to identify risk factors for adverse neonatal outcome. Correlation between SII duration and neonatal adverse outcome was analyzed.

RESULTS

Overall, 882 were analyzed. Most women (85.4%) were primiparous. Median gestation age at delivery was 40 ^2/7 weeks. Median time from SII to delivery was 170 min. Adverse neonatal outcomes occurred in 113 (12.8%) of deliveries. Duration of SII was not associated with adverse neonatal outcome. Analysis for determinants of adverse neonatal outcome revealed that oligohydramnios was more common in pregnancies with adverse neonatal outcome (7/113 (6.2%) vs. 41 (5.4%) OR [95% CI] 2.47 (1.02-5.98), p = 0.03). Duration of second stage of labor was longer in the adverse outcome group (median 179 min vs. 126 min, p = 0.008). Prolonged second stage was more common in the adverse outcome group (60 (53.1%) vs. 273 (35.5%) OR [95% CI] 2.05 (1.38-3.06), p < 0.001). On logistic regression analysis, prolonged second stage was the only modifiable factor independently associated with adverse neonatal outcome [adjusted OR 2.09 (1.37-3.2), p = 0.001]. Other variables tested did not differ between groups. Only phototherapy and base excess ≥ 12 mmol/L were significantly associated with the duration of second stage of labor; for each additional hour of the second stage, the OR for the former increased by 0.34 (p = 0.008), and for the latter by 0.69 (p = 0.007).

CONCLUSION

Duration of suspected intraamniotic infection was not associated with increased neonatal morbidity among women delivering vaginally at term. Prolonged second stage was a strong independent predictor of an adverse neonatal outcome among fetuses exposed to intraamniotic infection.

Novel coronavirus SARS-CoV-2 and COVID-19. Practice recommendations for obstetric anaesthesia: what we have learned thus far

SARS-CoV-2 is a novel coronavirus causing a global pandemic of a severe respiratory illness known as COVID-19. To date, globally, over 30,000 people have died from this emerging disease. As clinicians and healthcare systems around the world are rapidly adapting to manage patients with COVID-19, limited data are emerging from different patient populations to support best-practice and improve outcomes. In this review, we present a summary of emerging data in the obstetric population and offer obstetric and anaesthetic clinicians around the world a set of evidence-driven, practice-based recommendations for the anaesthetic management of pregnant women with suspected or confirmed COVID-19.

Practical recommendations in the obstetrical patient with a COVID-19 infection

La infección por COVID-19 afecta también a las pacientes obstétricas. La atención obstétrica habitual ha continuado a pesar de la pandemia. Existen series de casos de pacientes obstétricas. Parece que las técnicas neuroaxiales son seguras y es importante asegurarse que los bloqueos funcionen correctamente antes de una cesárea. Es por esto que se recomienda que los bloqueos sean realizados por anestesiólogos expertos. La protección y seguridad de los profesionales es un punto fundamental y, en caso de anestesia general, también se recomienda acudir al anestesiólogo más experto. Las pacientes gravemente enfermas deben reconocerse rápida y precozmente, para poder suministrarles el tratamiento adecuado lo antes posible. La susceptibilidad a las trombosis hace que la anticoagulación profiláctica sea prioritaria.

Obstetric analgesia in labor and its association with neonatal outcomes

OBJETIVE

To investigate the association between analgesia during labor and occurrence of neonatal outcomes.

METHOD

Retrospective cohort study with medical records of 850 parturient. The exposure variable of interest was receiving pharmacological analgesia during labor and neonatal outcomes were: one- and five-minute Apgar, resuscitation maneuvers and referral of the newborn to Neonatal ICU. A logistic regression was carried out to obtain Odds Ratios and 95% confidence interval, with adjustment for confounding factors.

RESULTS

Among the women studied, 35% received analgesia and this use was associated with a greater chance of neonatal outcomes such as one-minute Apgar < 7 (p <0.0001), resuscitation maneuvers (p <0.001) and referral to the Neonatal ICU (p = 0.004), mostly were among low-risk pregnant women, even after adjustments.

CONCLUSION

The use of pharmacological analgesia during labor is associated with one-minute Apgar < 7, resuscitation maneuvers and referral to the Neonatal ICU.

Does the presence of epidural analgesia reduce the risk of neonatal sepsis in the setting of an intrapartum fever?

Objective: Epidural analgesia has been associated with more frequent intrapartum fever as well as neonatal antibiotic therapy. We examined whether intrapartum fever carries the same risk for neonatal sepsis with and without epidural.Methods: This is a retrospective cohort study of 34,371 deliveries at a single institution. Primary outcome variables included neonatal sepsis, Apgar scores, neonatal intensive care (NICU) admission, postpartum hemorrhage, prolonged labor, and cesarean delivery. Univariate analysis and multivariable logistic regression were used to assess the risk of sepsis while controlling for possible confounding covariables.Results: A total of 34,371 patients were included in the study, 16,917 (49.9%) of whom had epidural anesthesia. Of the patients who had an epidural, 2103 (12.4%) had an intrapartum fever, compared to 446 (2.6%) of those who did not have an epidural (p < .001). Overall, there was a decreased risk of neonatal sepsis in the setting of intrapartum fever with an epidural after controlling for potential confounders. (aOR 0.53 [95% CI 0.29-0.98]). In preterm patients, an epidural was associated with a decreased risk for neonatal sepsis (5.7% vs. 10.0%, p = .04), 5-minute Apgar score <7 (23.5% vs. 33.6%, p = .006), and NICU admission (66.6% vs. 76.5%, p = .008) compared to those born in the setting of a fever without an epidural.Conclusions: Neonates were less likely to sustain a diagnosis of sepsis in the setting of an epidural-associated fever compared to those in the setting of an intrapartum fever without an epidural. These data may be used by providers in counseling and guideline creation.