We routinely place epidurals in such patients after they have received intravenous antibiotics. It is important to find the source of the infection. In our laboring patients, we find that chorioamnionitis is one of the major source of infection and subsequent fever.

In the absence of an obvious infective source I would not regard a core temperature of 38 as "febrile" during labour, and leucocytosis (even over 15000), predominantly neutrophils, can be part of the associated stress response. In the absence of signs or symptoms, I would have no issues with placing the epidural. I agree with Jaya about early chorioamnionitis as a possible cause for concern, particularly during a prolonged labour or after induction for prelabour rupture of membranes, in which case the patient would be on antibiotics already.

I am agree with Jaya and Cristopher that we can go for epidural labor pain analgesia

provide there is no obivious infected source and the

Patient already on antibiotics

Chris,

Thanks for your input. Do you have any concerns about epidural in patients with active HIV scheduled for Cesarean sections? Our Obstetricians start such patients on AZT loading dose followed by infusion for 4 hours( based on viral load) before cesarean delivery.

Not really. It has been a long time since the situation has arisen, and I haven't revisited the literature on this. Ordinarily we use spinal anaesthesia in this situation, and I haven't seen any problems wrt AZT. All the ladies I see are on continued ART therapy during pregnancy and I don't obsess about the exact timing of the AZT any more as viral loads are low, and the infants are commenced on early appropriate ART. It would be unusual to have a lady with HIV in labour with an epidural as C-section is elected as part of the PMTCT program. Do you have concerns?

I will advice to go for one shot spinal anasthesia

for post operative analgesia I would like to replace epidural analgesia with multimodal analgesia , including TAP (U/S transverse abdominis plane Blocks)

I agree to use single dose spinal anesthesia if measurse to decrease temperature failed

I agree to use single dose spinal anesthesia if measures to decrease temperature failed

As long as you have good hemodynamic parameters, spinal and epidural anesthesia are both good for labor analgesia. The only reason I wouldn't go for it is hemodynamic instability. For labor analgesia you can always put an epidural catheter and titrate the dose.

Provided that the patient is hemodynamically stable and have proper antibiotic caverege, I won't definitely deny her an epidural for relief of labor pain.

In this case I would place an epidural cath because usually infection is related to the intervention to be performed. But when sepsis is suspected a comprehensive diagnostic work up must be experienced and further check for hemodynamic and coagulation impairment would be a safer management

I prefer to avoid epidural  catherinsertion in   such this patient 

the fever could be related to chorioamnitis or the patient has prolong rupture membrane with multiple vaginal examination 

epidural it self may induce fever which exagerate the effect of this hyperthermia on the mother and baby 

http://mobile.journals.lww.com/anesthesia-analgesia/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2010&issue=12000&article=00022