Management of Intraoperative Fever During Cesarean Section
The safest approach to intraoperative fever during cesarean section is to maintain active temperature monitoring, implement aggressive warming measures to prevent hypothermia (which is far more common than true fever), and if true fever develops, investigate for infectious causes while continuing the procedure with appropriate antibiotic coverage already administered preoperatively.
Understanding Temperature Dysregulation During Cesarean Section
The critical distinction is between hypothermia (which occurs in 50-80% of patients undergoing spinal anesthesia) and true fever during cesarean delivery 1.
Hypothermia is the Primary Concern
Perioperative hypothermia occurs in 50-80% of cesarean deliveries under neuraxial anesthesia and is associated with surgical site infection, myocardial ischemia, altered drug metabolism, coagulopathy, prolonged hospitalization, and adverse neonatal outcomes including lower umbilical pH and Apgar scores 1.
Core temperature monitoring is poorly performed during neuraxial anesthesia; skin temperature readings are 2.0-4.0°C lower than core temperature 1.
Immediate Intraoperative Management Algorithm
Step 1: Verify True Fever vs. Measurement Error
Ensure appropriate temperature monitoring using axillary measurement with the sensor placed over the axillary artery with arms adducted, as this provides more accurate core temperature assessment during neuraxial anesthesia 1.
Distinguish between true fever (>38°C) and normal/hypothermic readings that may appear elevated due to improper measurement technique 1.
Step 2: Implement Active Warming Measures
Regardless of the temperature reading, active warming should be standard practice:
Use forced air warming devices on the upper body and extremities 1.
Warm all intravenous fluids being administered 1.
Increase operating room ambient temperature to reduce maternal and neonatal hypothermia risk 1.
Active warming significantly reduces temperature change (P=0.0002), decreases shivering episodes (P=0.0004), and improves umbilical artery pH (P=0.04) 1.
Step 3: Ensure Prophylactic Antibiotics Were Administered
First-generation cephalosporin should have been given within 60 minutes before skin incision 1.
In women in labor or with ruptured membranes, azithromycin addition confers additional reduction in postoperative infections 1.
If antibiotics were not given preoperatively and fever develops intraoperatively, administer them immediately as prophylactic antibiotics reduce endometritis risk by two-thirds to three-quarters 2.
Step 4: Continue Surgery While Investigating
True intraoperative fever during cesarean section is NOT an indication to abort the procedure:
Intrapartum fever is not an indication for cesarean delivery to interrupt labor for the purpose of improving neonatal outcome, and similarly, fever during an already-initiated cesarean should not alter the surgical plan 3.
The procedure should continue expeditiously while maintaining standard surgical technique 1.
Differential Diagnosis of Intraoperative Fever
Most Likely Causes During Active Surgery
Pre-existing chorioamnionitis (if patient was in labor or had prolonged rupture of membranes) - relative risk for endometritis is 8.7 4.
Epidural-related fever if labor preceded the cesarean section 3.
Transfusion reaction if blood products were administered 5.
Drug fever from medications administered perioperatively 5.
Less Common but Important Considerations
Aspiration or pulmonary complications from anesthesia 5.
Malignant hyperthermia (extremely rare but life-threatening - would present with additional signs including muscle rigidity, tachycardia, hypercarbia) - requires immediate recognition and treatment with dantrolene.
Postoperative Management After Intraoperative Fever
Immediate Postoperative Period
Monitor for signs of infection: The triad of fever, chills, and rapid rise in white blood cell count (from ~12 × 10³/µL to ~35 × 10³/µL) indicates significant infection requiring urgent evaluation 6.
Assess for surgical site complications: Subfascial hematomas can become secondarily infected and present with supra-umbilical tenderness and marked leukocytosis 6.
Imaging if Infection Suspected
Obtain contrast-enhanced CT of abdomen/pelvis if fever persists with rising leukocytosis or clinical deterioration to evaluate for subfascial collections, uterine dehiscence, or abscess formation 6.
Collections ≥3 cm with signs of infection require CT-guided percutaneous drainage 6.
Critical Pitfalls to Avoid
Do not assume all temperature elevations represent infection - hypothermia is far more common and requires active warming, not cooling measures 1.
Do not delay or abort surgery for isolated fever without other signs of maternal or fetal compromise 3.
Do not withhold antibiotics if they were not given preoperatively - administer them immediately as they substantially reduce infectious complications 2.
Do not interpret postoperative leukocytosis of 35 × 10³/µL as normal - this far exceeds typical post-cesarean elevation and signals significant infection requiring urgent intervention 6.
Do not place prophylactic subcutaneous drains as they do not prevent seroma or infection 7.
Special Considerations for Anesthesia Type
Neuraxial anesthesia is preferred and should not be avoided due to fever concerns, as it provides superior outcomes for pain control, organ function, and postoperative recovery compared to general anesthesia 1.
Regional anesthesia reduces contamination risk to healthcare workers and optimizes drug management 1.
General anesthesia in pregnant women carries higher risks of pulmonary aspiration and difficult intubation 1.