Epidural Plus Fever During Labor Put Baby at Risk

From: http://www.medpagetoday.com/Anesthesiology/Anesthesiology/30914

Epidural Plus Fever During Labor Put Baby at Risk

By Crystal Phend, Senior Staff Writer, MedPage TodayPublished: January 30, 2012

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Action Points

  • A temperature spike during labor with epidural analgesia may indicate serious risks for the baby in an otherwise low-risk delivery.
  • Point out that the risks of hypotonia, assisted ventilation, low Apgar scores, and early-onset seizures weren’t associated with epidural catheters when fever above 99.5°F didn’t occur.

A temperature spike during labor with epidural analgesia may indicate serious risks for the baby in an otherwise low-risk delivery, researchers found.

Infants whose mother ran a fever over 101°F while receiving an epidural were two- to six-fold more likely to be weak, need ventilation, have low Apgar scores, and experience early-onset seizures, reported Elizabeth A. Greenwell, ScD, and colleagues from various institutions affiliated with Harvard University in Boston. Greenwell is now at the University of Colorado Denver School of Public Health.

The same risks weren’t observed with epidural catheter use when fever above 99.5°F didn’t occur, the group pointed out in the February issue of Pediatrics.

“Although epidural analgesia is generally considered a safe and effective method of pain relief during labor, both randomized trials and observational studies consistently demonstrate an association between epidural and maternal fever during labor,” they noted.

Some evidence suggests epidurals induce an inflammatory response and boost cytokines levels that inflict neurologic damage.

Regardless of the cause of fever, these results from pregnancies not complicated by infection suggest that even a moderately elevated temperature could hurt the baby, perhaps because fetal core temperature runs at least 1°F higher than that measured in the mother, Greenwell’s group explained.

“Although many of the specific outcomes we found associated with elevated maternal temperature may be transient, it is possible that particularly the increase in early-onset neonatal seizures could have implications for longer-term health of the infant,” they acknowledged.

Whether trying to cool down a woman during labor once the fever is detected would reduce risk for the baby isn’t clear, the group cautioned.

They studied outcomes for all women giving birth to their first child at term at Boston’s Brigham and Women’s Hospital in 2000. The patients did not have documented sepsis, meningitis, or major congenital anomaly.

Just 13% of these 3,209 low-risk women opted against an epidural during labor.

Fever of more than 100.4°F developed during labor in 19% of epidural users compared with just 2% of those who went without (P<0.0001).

Lower grade temperatures were also more common with epidural use. Overall, 45% of women who received an epidural had a temperature of at least 99.5°F during admission for delivery compared with 13.2% among women without an epidural.

Undergoing an epidural without developing a temperature didn’t appear to have any affect on infant outcomes measured.

But the higher a woman’s temperature while delivering with an epidural, the higher the risk to the baby. Comparing maternal temperature of 99.5°F or lower to one over 101°F, the results were:

  • Transitional hypotonia prevalence rose from 11% to 25% (P<0.001)
  • Hypotonia lasting more than a quarter of an hour rose from less than 1% to 3% (P=0.0005)
  • Requirement for substantial resuscitation efforts at birth rose from 4.4% to 12.2% (P<0.0001)
  • Apgar scores under 7 at one minute after birth rose from 6.4% 13.5% (P<0.0001)
  • Apgar scores under 7 at five minutes after birth rose from 0.3% to 2.1% (P=0.0007)

After adjustment for maternal age, baby’s birth weight, duration of labor, and method of delivery, these risks were all significant at a fever of more than 101°F.

A temperature of 99.6° to 100.4°F also significantly predicted more transitional hypotonia and poor Apgar scores at one minute. A temperature of 100.5° to 101°F also predicted poor Apgar scores at one minute along with hypotonia lasting more than 15 minutes.

Only eight infants developed early-onset seizures, but four had been exposed to a maternal temperature over 100.4°F during delivery. Compared with women whose temperature never went over 99.5°F, that represented a 6.5-fold higher risk.

The researchers cautioned that few women in the low-risk population developed a fever in the absence of epidural use, which precluded analysis of whether fever was more dangerous in the setting of an epidural.

Bias from a pediatrician being in the room more frequently when women develop fever during labor likely wasn’t responsible for the difference in outcomes, because the results were similar for women running temperatures of 99.6° to 100.4°F for which pediatricians wouldn’t be called in, the group noted.

Undetected maternal or infant infection was plausible but unlikely to be responsible for the findings either, they added.

The study was supported in part by an award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The researchers reported having no conflicts of interest.

Childbirth Classes in Full Swing!

New Year! New Projects and our Childbirth teaching is primo on our list. We have had SUCH a blessed year in 2009 with 30 – THIRTY!!!! babies that we have helped welcome to the world. It has just been joyous! Thank You! Thank You! Thank You!

So, onto getting our teaching established better. We will be teaching mainly out of Julia’s home which is more centrally located in the city area. Plan to have continual 5 week childbirth classes running and if demand gets high we will adjust to fit those schedules. As of now, a class will consist of 4 couples so will be nice and small, yet big enough to do our fun games and hands on activities. Our first class is planned to begin next week Wednesday, January 20th. There is still space in this class if you are due around March or early April. (Or have friends or clients due…let them know) We also have one beginning on March 31st for 5 weeks. Just contact one of us if you want to get in on these classes. We will post others as they are scheduled.

I want to leave you will a wonderful story that my amazing VBAC Twin mom from March sent to me. It is about VBAC TRIPLETS!!! It was in Georgia and I totally tip my doula hat to that doc, hospital and especially the MOM!!! Women are so amazing!

http://doulamomma.wordpress.com/2010/01/08/triplet-vbac-in-ga-with-dr-tate/

Spinning Those Babies

Babies fit best when they come out facing your back. Lately there has been a rush on “sunny side up” babies where they are pushing their bony little heads into that tailbone of yours. This can cause undo pain called “back labor”. There are a few reasons these babies are spinning out of control…

  1. Mom’s are positioning themselves so that the heaviest part of baby (their head and spin) let gravity pull them toward the back instead of keeping them rounding that belly outwards. These positions are when you get home from work and want to put your feet up so you recline back. Or maybe your recliner has become your best friend to sleep in so that you aren’t suffering from the reflux from dinner…or lunch…or breakfast. Still in that back lying position, it encourages baby to spin its back toward the ground…ie your back. Amazingly, how we are created…just standing, our pelvis is tilted so that baby is encouraged in the right position. If you want to lie on your side, really pitch yourself forward so that gravity is still bringing baby’s back outward.
  2. Happening in labor…the epidural. I have seen it time and time again….epidural = baby in asynclinic position (fancy name for not lined up right). Labor is longer, harder, and ultimately if baby doesn’t turn or come down….c-section or assisted delivery with vacuum or forceps. Positioning while having an epidural can help, but the relaxation of the pelvic floor that can happen with an epidural can sometimes just not allow the baby to that the ideal condition for them to be able to spin. They kinda sink into it and stay in whatever position they find. Usually facing forward or side.

Being aware of what you can do before labor and in labor if baby seems to be facing less than ideal directions is key. www.spinningbabies.com is a great site to check out for good info on this and other positioning ideas. Check it out and GET OFF YOUR BACKS!

H1N1 Flu and/or Seasonal Flu Vaccine? Read this first!

http://articles.mercola.com/sites/articles/archive/2009/11/03/What-We-Have-Learned-About-the-Great-Swine-Flu-Pandemic.aspx

This is an amazing research based article on many facts about the swine flu, seasonal flu and the vaccines available to help prevent them, that have not quiet made it into mainstream knowledge. Please take a few minutes to educate yourself.

We are all responsible for our own health. We have the ability now days to do very in depth research and not just have to rely on others to give us their opinions or information filtered through their views. I am in no way saying the medical community is out to get us. On the contrary, I believe them to be in their positions because they care for people and want to look out for us. I appreciate their opinions and use them in my own decision making process. But I am so very thankful that with the internet and the network of people we surround ourselves with, we can find good evidence based information to help us make informed well rounded decision about our health and the health of our families – born or unborn. It takes time to sift through the anecdotal info for hard facts, but worth it. Invest in your self, your health and your future!

Listening to Mothers II 2006 report

http://www.childbirthconnection.org/article.asp?ck=10396

In class I realized I was giving out information from the 2002 Listening to Mothers I report. Although very similar, I thought would be good to give you access to the 2006 report. It only recently came available for free and I will update my information! It is LONG but can scan through for things might be interested in. I thought pg 34 was interesting with all the interventions and how often they were used as well as the information on inductions. Nothing about the low amnio fluid. It shows me how “new” this cause for induction. I wonder where it will place on the next survey!

Take this information and add it to you mental toolkit you bring with you to appointments and into labor. I give this to you to help you recognize the birth you would like and the reality of what is happening in deliveries so that you can be prepared to A) change your plan a bit to adjust to what the norm is so as to not be taken off guard. and/or B) advocate for the things you have researched to be most beneficial to the outcome you would like.

While some of you have had a medical journey up to the point of conception, you have been doing this all on your own up to today. Your body has been taking care of this baby and growing and feeding and loving and nurturing and protecting and surrounding it with so much good things! The reasons for any medical aspects needing to take part in your process of taking care of your baby on the outside rather than the inside are VERY minimal. Labor and delivery and parenting afterward are all just an extension of what you are doing already. And doing it beautifully! Keep up the good work!

The Magical Bond of Motherhood

As a mother a women is another person than the women without child. She carries the fruit of the night for nine months in her body. Something grows into her life that never again departs from it. She is a mother and remains a mother even though her child dies. For at one time she carried the child under her heart and it does not go out of her heart ever again.

An Abyssinian noblewomen quoted by Leo Frobenius in Der Kopf als Schicksal

I love birth!

I Love Birth!  Sometimes I just have to shout it out for the world to hear (or – just our limited circle of bloggers, but hey…) – I Love Birth!

Last week I had the privilege of attending a wonderful, natural, normal birth.  This was the birth of a beautiful baby girl, whose mama happens to be a friend.  But I wasn’t the only support person – oh, no.  This mama was supported by a terrific husband who never left her side.  But it wasn’t just the two of us laboring with mama.  This mama was supported by a very close friend, who had also been present at her first birth.  But, no, that isn’t the end either.  This mama was also supported by another good friend who offered to be present for encouragement and help.  And do you know?  This mama kept all of us busy, all of the time.

At one point, I do believe that I had tears of joy in my eyes at the sight we made.  One of those surreal moments when you look down on the scene from somewhere outside of yourself.  Mama was in the tub, gently rocking and sounding through each surge as her body made way for this new little one.  Dad sat at the end of the tub, offering his support through gentle words of encouragement and his near presence.  I was next in line, scooping up warm water with a basin and gently pouring it back and forth across mama’s belly with a rhythmic motion.  One friend held her hand and kept cool cloths on mama’s head, and another began a soothing reading about gentle birth choices in a dreamy, sing-song voice.  It was inspiring.

No matter what else took place during the course of that mama’s labor, that moment was normal, natural birth and it was unforgettable.

I love my job.

Birthdays…A Rite of Transition

What is a Birthday, anyway?  Wikipedia tells us that, “Birthday is the name given to the date of the anniversary of the day of a person’s birth… Birthdays are traditionally marked by celebrations including a birthday party or, in some particular cases, a rite of transition.”

When our children are born, they are not the only ones to experience a Birth Day.  We, as adults, enter our own rite of transition on this special day… we become parents.  Somehow our hearts grow bigger, our days grow more full, our minds grow busy with the anticipation of what lies ahead, and our lives are forever touched by something so small and precious.  Time seems to stop for one amazing moment.

Someone once said that birth is like having your heart step outside your body and walk around in the world on its’ own two feet.  Happy Birthday, Heart.

Our own Christy Muscato celebrates her Birth Day this weekend… Happy Birthday, Friend – I’m so glad you were born!

Trusting Birth

Things you can trust about birth…

  1. Birth is natural… and you are beautifully designed to carry and birth the baby within.
  2. Birth is powerful… the physical road, the emotional path, the mental marathon – the whole journey is powerful.  And amazing.
  3. Birth doesn’t have to happen to you… it is a part of you.
  4. Birth is an inward journey with an outward purpose… sculpting and molding your soul as it draws forth an amazing masterpiece.
  5. Birth is a gift… you unwrap strength, courage, and beauty one layer at a time.  Whatever your story, you can rejoice in what you find inside.

What do you know to be true about birth?

Community

Women are cool. We just naturally feel the need to bond and take care of other women. Even when I meet or have contact with a woman that doesn’t strike me as “best friend material”, my brain still starts going through all the ways I might be able to support her through whatever trial she is going through. I am sure we have all had those women who have even been mean or hateful to us, but if/when we find out they are struggling or unhappy about something (usually why they lash out with bad vibes to begin with) our anger and hurt melts a bit and that caring community nature begins to bubble up to the top. We are just designed that way.

I just helped our own Pat Predmore, local and national pillar in the birth community, with her Birth Doula Workshop. I have to say we are SOOO lucky to have Pat here teaching your local doulas. She is the trainer of all the trainers of doula nationwide for DONA, International. She is amazing and really knows her stuff. Julia and I were both in the same Birth Doula Workshop 4 ½ years ago and are so honored to have had that opportunity to learn and continue to learn under her. Point being….she empowers the BEST doulas and a whole new batch of them just finished their training on Sunday. Julia and I both try and help out when Pat does a training and I take away something from each group and what really struck me this time is what a sense of community I felt. It is always reaffirming to meet and bond with women who are as “coo coo for cocoa puffs” for birth stuff as you are, but I was just so proud to see these strong amazing women going forth with a mission to help and support their community of women. Doula-ing in definition is involved in birth or the postpartum period, but those of us who are doulas know that doula-ing happens all the time between women in many different circumstances. So tap into your own inner doula and allow yourself to be aware of what is going on in your own communities of women and beyond. Find ways you can support women. Take that step outside of yourself. I promise you it is rewarding beyond measure.