Management of Maternal Fever During Labor
Maternal fever during labor (≥38.0°C/100.4°F) should be promptly treated with broad-spectrum intrapartum antibiotics—specifically ampicillin (2g IV initial dose, then 1g IV every 4 hours) plus gentamicin (weight-based dosing)—while simultaneously investigating for chorioamnionitis and other infectious causes. 1
Diagnostic Approach
Clinical diagnosis of chorioamnionitis requires maternal fever (≥38.0°C) PLUS at least one additional finding: 1, 2
- Maternal tachycardia
- Fetal tachycardia
- Uterine tenderness
- Foul-smelling amniotic fluid
- Maternal leukocytosis
Important caveat: Epidural analgesia causes fever in 15-25% of patients through a sterile inflammatory process, making it the strongest risk factor for intrapartum fever (adjusted odds ratio 5.5). 3, 4 However, do not delay antibiotic treatment while attempting to distinguish epidural-related fever from infectious causes, as this distinction cannot be made reliably at the bedside. 4
Antibiotic Management
Standard regimen (no penicillin allergy): 1
- Ampicillin 2g IV initial dose, then 1g IV every 4 hours until delivery
- PLUS Gentamicin (loading dose followed by weight-based maintenance dosing)
Non-severe penicillin allergy: 1, 2
- Cefazolin 2g IV initial dose, then 1g IV every 8 hours until delivery
- PLUS Gentamicin
Severe penicillin allergy: 1, 2
- Clindamycin 900mg IV every 8 hours OR Vancomycin 1g IV every 12 hours until delivery
- PLUS Gentamicin
Timing is critical: Antibiotics should be initiated within 3 hours of fever recognition, or within 1 hour if septic shock is suspected. 5 Blood cultures should be obtained before antibiotic administration when feasible. 5
Maternal Benefits and Risks
Antibiotic treatment reduces: 6
- Postpartum fever (adjusted odds ratio 0.42)
- Treatment for postpartum endometritis (3.53% vs 11.31% without antibiotics)
Labor management considerations: 7
- Intrapartum fever increases risk of cesarean delivery by 2-3 fold due to impaired uterine contractility
- Fever increases postpartum hemorrhage risk by 2-3 fold
- Have uterotonic agents immediately available at delivery to prevent treatment delays 7
- Fever itself is NOT an indication for cesarean delivery to improve neonatal outcomes 7
Neonatal Management
Well-appearing newborns born to mothers with chorioamnionitis require: 1, 2
- Limited evaluation: blood culture and CBC with differential
- Empirical antibiotic therapy (IV ampicillin for GBS coverage) pending culture results
Newborns with signs of sepsis require: 1
- Full diagnostic evaluation: blood culture, CBC with differential, chest radiograph if respiratory symptoms, lumbar puncture if stable
- Empirical broad-spectrum antibiotics including IV ampicillin (for GBS and E. coli coverage)
Critical context: The actual risk of early-onset neonatal sepsis in term infants born to febrile mothers is low at 0.24% (1 in 417). 8 However, maternal fever >39°C increases neonatal encephalopathy risk (4.4% vs 1.1% with fever 38-39°C), particularly when combined with fetal acidosis. 7 This justifies the precautionary approach to neonatal evaluation and treatment.
Adjunctive Measures
Acetaminophen: May be administered but has limited efficacy in reducing maternal temperature once fever develops. 7 A non-significant trend toward decreased failure to progress was noted with acetaminophen use. 3
Avoid hyperthermia: The goal is normothermia, as hyperthermia adversely impacts uterine contractility and may lower the threshold for fetal hypoxic brain injury. 5, 7
Prevention Strategies
Reducing fever incidence: 7
- Maintain labor progress through active management
- High-dose oxytocin regimen (6×6 mU/min vs 2×2 mU/min) reduced intrapartum fever rates from 15.6% to 10.4%
- Duration of epidural exposure and prolonged labor are modifiable risk factors
Risk factors to monitor: 3
- Epidural analgesia (strongest association)
- Prolonged second stage of labor
- Prolonged rupture of membranes
- Meconium-stained amniotic fluid
Common Pitfalls
- Do not withhold antibiotics pending amniocentesis results or waiting for maternal fever to develop in suspected chorioamnionitis 5
- Do not perform cesarean delivery solely to reduce fetal exposure to fever—there is no evidence this improves neonatal outcomes 7
- Do not assume epidural-related fever is benign—treat all intrapartum fevers as potentially infectious until proven otherwise 4
- Be prepared for postpartum hemorrhage—have multiple uterotonic agents ready at delivery 7