99% of Women Who Were Upright and Mobile During Birth Said They Would Make the Same Choice Again

Research

Upright versus lying down position in 2nd stage of labour in nulliparous women with low dose epidural: BUMPES randomised controlled trial

BMJ 2017; 359 doi: https://doi.org/x.1136/bmj.j4471 (Published 18 Oct 2017) Cite this equally: BMJ 2017;359:j4471

The Epidural and Position Trial Collaborative Group

Correspondence to: Peter Brocklehurst p.brocklehurst{at}bham.air-conditioning.uk

Accepted seven September 2017

Abstract

Objective To determine whether being upright in the second stage of labour in nulliparous women with a depression dose epidural increases the take chances of spontaneous vaginal birth compared with lying down.

Pattern Multicentre pragmatic individually randomised controlled trial.

Setting 41 UK hospital labour wards.

Participants 3093 nulliparous women aged sixteen or older, at term with a singleton cephalic presentation and in the second phase of labour with epidural analgesia.

Interventions Women were allocated to an upright or lying down position, using a secure web based randomisation service, stratified by center, with no masking of participants or clinicians to the trial interventions.

Principal consequence measures The master outcome was spontaneous vaginal nascence. Women were analysed in the groups into which they were randomly allocated, regardless of position recorded at whatever time during the second stage of labour (excluding women with no valid consent, who withdrew, or who did not reach second stage before delivery). Secondary outcomes included mode of nascency, perineal trauma, infant Apgar score <iv at 5 minutes, admission to a neonatal unit of measurement, and longer term included maternal concrete and psychological health, incontinence, and infant gross developmental filibuster.

Results Between 4 October 2010 and 31 Jan 2014, 3236 women were randomised and 3093 (95.vi%) included in the primary analysis (1556 in the upright group and 1537 in the lying down group). Significantly fewer spontaneous vaginal births occurred in women in the upright group: 35.2% (548/1556) compared with 41.1% (632/1537) in the lying down group (adjusted risk ratio 0.86, 95% confidence interval 0.78 to 0.94). This represents a 5.9% absolute increase in the gamble of spontaneous vaginal birth in the lying down group (number needed to treat 17, 95% confidence interval 11 to 40). No prove of differences was establish for most of the secondary maternal, neonatal, or longer term outcomes including instrumental vaginal delivery (adjusted chance ratio 1.08, 99% confidence interval 0.99 to one.18), obstetric anal sphincter injury (1.27, 0.88 to 1.84), babe Apgar score <four at v minutes (0.66, 0.06 to 6.88), and maternal faecal incontinence at one year (ane.18, 0.61 to ii.28).

Conclusions Evidence shows that lying down in the second stage of labour results in more spontaneous vaginal births in nulliparous women with epidural analgesia, with no apparent disadvantages in relation to brusque or longer term outcomes for female parent or babe.

Trial registration Current Controlled Trials ISRCTN35706297.

Introduction

Equally the most effective grade of pain relief in labour, epidural analgesia is called by approximately 30% of women in the United kingdom of great britain and northern ireland each yr, and this proportion has remained relatively stable over the past decade.12 Epidural analgesia leads to prolongation of the second stage of labour (from full dilation of the neck until birth) and an increased run a risk of instrumental vaginal delivery. Nonetheless, this testify comes by and large from trials that used epidural techniques which cause dense neuraxial blockade.3 Epidurals that utilize low dose local anaesthetic in combination with opioids result in a lower risk of instrumental vaginal commitment, just the rate of such delivery is still higher than among women with no epidural.45 Maternal position during the second stage of labour has been suggested to affect the hazard of instrumental vaginal delivery. A Cochrane review of position in the second stage of labour in women without epidural showed a reduction in instrumental vaginal delivery in the upright group, although the quality of the included trials was reported to be generally poor.6 Maternal mobility is limited with dense neuraxial blockade. Low dose epidurals preserve motor function, allowing greater mobility throughout labour and enabling women to adopt upright positions. A Cochrane review of position in the second stage of labour for women with epidural analgesia was published in 2017, afterward the current (Birth in the Upright Maternal Position with Epidural in Second stage: BUMPES) trial was started. This review included trials that compared upright with recumbent positions and suggested no effect. The run a risk ratio of operative nascence (caesarean section or instrumental vaginal commitment) reported in the v included trials, comprising 879 women in total, was 0.97 (95% conviction interval 0.76 to 1.25).vii In this group of women therefore, the debate remains about whether an upright posture in the second stage of labour increases the incidence of spontaneous vaginal birth.89

The aim of the BUMPES trial was to evaluate whether, in nulliparous women with low dose epidural analgesia, being upright during the second stage of labour increased the take chances of spontaneous vaginal birth, compared with lying downwards.

Methods

Study design and participants

This was a pragmatic randomised controlled trial carried out in UK motherhood units. Women were eligible for the trial if they were sixteen years or older, were at 37 weeks or more gestation, nulliparous (no previous birth ≥24⁺⁰ weeks' gestation), had a singleton cephalic presentation, and intended to have a spontaneous vaginal birth. They had to be in the second stage of labour, have a low dose epidural in situ (administered according to local unit of measurement protocol) during the first stage of labour that provided effective hurting relief, and be able to understand documents in English and provide written answers in English language.

Women were provided with written information about the trial during pregnancy and again in labour. They could requite written informed consent during the first stage of labour but were not eligible to be randomised until the 2nd stage of labour had been confirmed. Diagnosis was based on usual clinical criteria, either when the cervix was fully dilated on a vaginal examination (no boosted vaginal examinations were specified as part of the trial protocol) or when the presenting part was visible.

Randomisation and masking

Women were randomised to the allocated intervention (allocation ratio 1:1) using a secure spider web based central randomisation service hosted past the National Perinatal Epidemiology Unit Clinical Trials Unit of measurement, University of Oxford. To ensure that the recruiting staff could not reliably predict the next allocation, the randomisation schedule used random permuted blocks of sizes two, 4, 6, 8, and 10, randomly selected according to the ratio specified by Pascals' triangle (1:4:vi:8:10). Stratification was by centre. Owing to the nature of the intervention, it was non possible to mask the women or clinicians to the trial intervention.

Procedures

Women were allocated to a policy of an upright position, which would maintain the pelvis in as vertical a aeroplane as possible during the 2nd stage of labour, with the intention of continuing the allocated position until the birth (this could include walking, standing, sitting out of bed, supported kneeling, commodities upright in an obstetric bed, or any other upright position for as much of the second phase equally possible); or a lying downwardly position (left or correct lateral, to prevent aorto-caval compression, with upward to 30 degrees inclination of the bed), which would maintain the pelvis in every bit horizontal a plane as possible during the second phase of labour, with the intention of continuing the allocated position until the birth. Considering midwives in the UK routinely provide care for women in labour, they administered the intervention. Before the beginning of the trial, the midwives received grooming to emphasise the importance of supporting mothers in their allocated position, especially for the passive second phase of labour (the menstruum earlier pushing commences, which can final 1 to 2 hours). As this trial was pragmatic we expected that there would be "unavoidable" reasons for changing maternal position—for example, fetal distress, fetal blood sampling, or to assist improve pushing in the active second phase. Women were free to change position if they wished at whatever stage after trial entry.

From infirmary notes we collected information at trial entry virtually maternal characteristics (including index of multiple impecuniousness,10 an area measure of impecuniousness derived from the mother's postcode), pregnancy complications, and progress of labour before trial entry. Information on adherence to the allocated intervention were collected every 15 minutes when the attending midwife recorded what position the woman was in "for the bulk of the time since the last assessment" and, if this position had changed from the allocated position, recorded the reasons for this alter. Information on clinical issue subsequently nativity likewise as neonatal outcomes and infirmary inpatient stay was collected after the birth from hospital records. Equally soon as possible afterward delivery, the woman was asked to complete a one page questionnaire about satisfaction with her birth feel (encounter supplementary appendix). Women with infants who survived and resided with them were followed upwards at ane twelvemonth using a self administered postal questionnaire asking about specific health problems and their general health and wellbeing, also as that of their babe.

Outcomes

The primary outcome measure was spontaneous vaginal birth. Secondary short term outcomes were instrumental vaginal delivery (forceps and ventouse), caesarean section, augmentation of labour, major interventions to maintain blood pressure level (eg, vasopressors), hypotension (systolic claret pressure <100 mm Hg before delivery), application of fetal scalp electrode, fetal claret sampling, full doses of epidural local anaesthetic and opioids administered after randomisation, duration of active second stage (time from pushing to delivery), elapsing of 2nd stage of labour (time from randomisation to delivery), boosted anaesthesia used for operative delivery, active direction of the third stage, episiotomy, pain during delivery (assessed using a visual analogue scale, with 0 as no pain and 10 as worst pain imaginable), genital tract trauma, manual removal of the placenta, primary postpartum haemorrhage requiring blood transfusion, duration of maternal inpatient stay after delivery, and satisfaction with the experience of birth. For the neonate, secondary outcomes were metabolic acidosis (cord artery pH <7.05 in 2nd phase, with base arrears ≥12 mmol/Fifty), presence of meconium stained liquor, Apgar score <iv at five minutes, resuscitation at birth, skin to peel contact within the offset hour of birth, initiation of breast feeding inside the first hour of nascence, duration of neonatal inpatient stay, and admission to neonatal unit and duration of stay. Secondary outcomes at ane year for the female parent were urinary incontinence, faecal incontinence, other bowel issues, dyspareunia, full general concrete and psychological health, and health related quality of life measured with the EQ-5D-3L and SF-12 instruments.1112 Secondary outcomes at one year for the baby were major morbidity (eg, gross neurodevelopmental delay, including cerebral palsy) and infirmary admissions.

Statistical analysis

Assuming a rate for the primary outcome of spontaneous vaginal birth of 55% in the command group (derived from information published from the COMET trial4) and a two sided 5% significance level, nosotros required a sample size of 3000 women. This had 90% ability to detect an accented difference of half-dozen% in the spontaneous vaginal birth rate between the two policies, equivalent to a risk ratio of 1.11. On collation of the pilot data for an acting analysis presented to the independent data monitoring commission in 2011, it was recognised that the combined primary outcome event charge per unit was lower than predictable, at 34%, 95% confidence interval 26% to 42% (based on 49/145 events, combining upright and lying down groups). With a reduction in the control grouping effect rate (from an anticipated 55% to betwixt 30% and 40%), keeping the sample size fixed at 3000 meant that a risk ratio of between i.13 and 1.19 would be detectable, equivalent to an absolute risk increment of 5% to 6%. Although ability was insufficient to observe a gamble ratio as small as the planned 1.eleven, the absolute risk detectable was similar and the trial steering committee agreed that changes to the target sample size were unnecessary.

Before analysis of the trial information the trial steering commission developed and approved a detailed statistical analysis plan. Women were analysed in the groups into which they were randomly allocated, regardless of position recorded at any time during the 2d stage of labour (an intention to treat assay). We excluded women from the assay if a valid consent form was not received past the central written report team, consent to apply their data was withdrawn, they were not in 2nd phase of labour when randomised and did non attain 2nd stage before delivery, or they were not in labour or without an epidural in place at the time of randomisation. All comparative analyses were performed using generalised linear models with heart as a random intercept. Binary outcomes were analysed using log binomial regression models, and results are presented as adjusted risk ratios with respective conviction intervals. Where possible we analysed continuous outcomes using linear regression models, and results are presented as adjusted differences in means with associated conviction intervals. Unadjusted Hodges-Lehmann median differences (plus confidence intervals) for skewed continuous variables are presented. The geometric hateful indicates the central trend or typical value of a set up of numbers by using the product of their values (as opposed to the arithmetics mean which uses their sum) and is used for summarising skewed data. Comparative assay uses a ratio of the geometric means instead of the mean difference and therefore a ratio of 1 indicates no difference between the groups. For the primary consequence nosotros present 95% conviction intervals, and for all other outcomes 99% confidence intervals to allow for cautious interpretation of the results.thirteen

Positions recorded were categorised according to whether the women were lying down, upright, or in "other" positions for each 15 minute interval. Positions recorded every bit lithotomy were categorised as "lying downwardly" since the pelvis is in a horizontal position. A summary of adherence to allocated position is reported by trial arm for the passive second stage (ie, before pushing commenced), the agile second phase (ie, pushing), and the whole of the second stage. Summaries of adherence information were calculated equally the proportion of 15 minute intervals a woman spent in the position to which she was allocated out of the full number of xv minute intervals recorded in the passive, agile, or whole of the 2d stage of labour. Medians and interquartile ranges are presented attributable to the skewed distribution of the information. Hodges-Lehmann differences in medians with corresponding 95% conviction intervals are presented by randomised group. The trial statistician and an independent clinical assessor reviewed and classified all reasons for changes in position as avoidable or unavoidable. Periods where changes to a non-allocated position were considered necessary for unavoidable reasons were treated every bit adherent.

The self completed maternal satisfaction questionnaire included a question about what position the women were in for most of the time during the passive and agile stages of labour, with responses "lying down," "upright," "other," and "can't remember." We summarise these data past trial arm using counts and percentages.

To examine whether the effect of the policy of position during the 2nd stage of labour was consistent beyond prespecified subgroups, nosotros undertook the following subgroup analyses: gestational age (37⁺⁰ to 38^{+half dozen}; 39⁺⁰ to xl⁺⁶; and ≥41⁺⁰); maternal age (≤24, 25-29, thirty-34, ≥35); augmentation with oxytocin in the showtime stage of labour (yes or no); and index of multiple deprivation (population based fifths 1 to 5).

Nosotros farther adapted the analysis of the master event to investigate the bear on of known prognostic factors (historic period, ethnicity, diagnosis of delay, onset of labour—induced versus spontaneous).

On a restricted dataset we carried out a sensitivity analysis on the one year maternal outcomes, excluding all women who were pregnant or had had another child at the time of completing the ane year follow-upward questionnaire.

The time from randomisation to trial entry, and all other durations, are prone to errors because of time differences recorded in different locations of the maternity units. The time of randomisation is accurate as this was recorded by the estimator server providing the randomisation service. However, all other times depended on the accuracy of the clocks in the different locations. For instance, the clock on the cardinal midwifery station might have read a slightly different fourth dimension to that in the labour room, and these might both have been dissimilar from the clock in theatre. Many relatively pocket-sized bug occurred with derived duration variables in the dataset (eg, negative values), suggesting variation in actual time recorded between dissimilar settings. Stata version 13 was used for all analyses.

The trial was overseen by a trial steering committee and an independent information monitoring committee. The information monitoring committee used the Haybittle-Peto arroyo to stopping guidelines for interim analyses using three standard errors as the cut-off for consideration of early cessation, preserving the type 1 mistake beyond the trial.xiv

Patient and public interest

The public was involved throughout the blueprint, conduct, analysis, and interpretation of this trial. One patient and public involvement co-investigator (MN) attended all the planning meetings and was involved in drafting the funding application, developing the detailed trial protocol and data drove forms, conducting the trial meetings, and writing the report and paper. MN took a lead in helping the team develop participant information leaflets to be used in the antenatal period and at the time of labour, as well every bit helping program dissemination activities and drafting and developing the summary information for the public.

Results

Between 4 October 2010 and 31 Jan 2014, 3236 women were randomised to the BUMPES trial from 41 participating centres (fig one⇓ and see supplementary tabular array). This deliberate over-recruitment was to compensate for women being excluded from the analysis. A full of 143/3236 women (iv.four%) were excluded from the analysis of the primary outcome (fig i⇓). Nigh of these exclusions were because of missing or incomplete consent forms. For 32 women, exclusion was considering they were randomised in error. Information at the time of birth were available for 100% of women recruited and analysed. Follow-up data at one year were received from 1892/3093 (61.two%) women. The median fourth dimension to completion of the questionnaire from birth was 11.9 months (interquartile range xi.7-12.vii) in each group.

Baseline characteristics were broadly similar between the two arms of the trial (table 1⇓). Most of the women in both arms were between 37 and 41 completed weeks of pregnancy, although 7.5% (231/3093) of women were 42 weeks or more. The majority of women participating in the trial were of white ethnic origin and the mean torso mass alphabetize at booking was just over 25 kg/m^two. Approximately 40% of women had their labour induced. About 80% of women could perform a straight leg raise at the time of trial entry suggesting that they had reasonable mobility with their epidural analgesia. There was an apparent disparity between the 2 groups in the position of the women at the time of trial entry; a greater proportion of women who were lying down in the group allocated lying downwards compared with those in the upright position. The fashion these data were requested is likely to take led to misclassification of this variable, in that midwives may have recorded the position of the women at the time of allocation (ie, after they had already assumed the allocated position). As all other characteristics of the women were similar at baseline information technology seems unlikely that this represents the truthful position at the fourth dimension of randomisation; rather it is a combination of this plus bodily allocation.

Tabular array 1

Baseline characteristics of analysis population. Values are numbers (percentages) unless stated otherwise

Adherence to the intervention was generally good. The median proportion of time spent in the allocated position during the passive second phase (before pushing commenced) was 1.0 (interquartile range 1.0-1.0) in the upright grouping and 1.0 (0.67-1.0) in the lying down group (median difference 0, 95% confidence interval 0 to 0). As predictable, adherence was poorer in the active second phase, with the median proportion of fourth dimension spent in the allocated position 0.88 (0.60-1.0) in the upright group and 0.75 (0.38-1.0) in the lying down group (median difference 0, 0 to 0) (tabular array 2⇓, fig 2⇓). The information provided by women about their position in labour was broadly like to this, with 75.8% (794/1047) of women in the upright group stating that they were mostly in the upright position during the passive stage and 72.three% (752/1040) of women in the lying down group stating they were mostly lying down. In the active stage, 72.5% (745/1028) of women in the upright group recalled being mostly upright, and 63.vii% (652/1024) of women in the lying down group recalled more often than not lying down (tabular array two⇓).

Table 2

Proportion of time spent in allocated position. Values are numbers (percentages) unless stated otherwise

A clear statistically pregnant difference (at the 5% level) in the incidence of the primary outcome of spontaneous vaginal birth was found between the groups, with 35.ii% (548/1556) of women achieving spontaneous vaginal birth in the upright group compared with 41.ane% (632/1537) in the lying downwardly group (adjusted gamble ratio 0.86, 95% confidence interval 0.78 to 0.94) (table 3). This represents a 5.ix% absolute increment in the adventure of spontaneous vaginal birth in the lying down group (number needed to treat 17, 95% conviction interval 11 to forty). This result was unchanged when adjusting for age, ethnicity, diagnosis of filibuster, and the nature of the onset of labour (adjusted risk ratio 0.86, 95% confidence interval 0.79 to 0.94).

We found no evidence of a divergence for virtually of the secondary maternal outcomes later study entry and during the 2d stage of labour (tables 3 and iv⇓). The elapsing of the active second stage of labour showed a statistically significant departure at the ane% level, with a shorter duration of labour in the lying down group (median difference of 7 minutes, 99% conviction interval 0 to 13). Other secondary maternal outcomes, such as instrumental vaginal delivery, caesarean section and perineal trauma, were suggestive of an increased risk associated with the upright position, merely these differences were not statistically significant at the ane% level. For example, the incidence of episiotomy increased in the upright group (58.8%, 914/1556) compared with the lying down grouping (54.6%, 838/1537) (although not statistically meaning at the ane% level). There seemed to be a higher incidence of obstetric anal sphincter injury in the upright group (6.vii%, 104/1556) compared with the lying down group (v.3%, 81/1537), but again this difference was not statistically pregnant at the i% level (table 3⇓).

Tabular array 3

Maternal main and secondary outcomes. Values are numbers (percentages) unless stated otherwise

Table 4

Neonatal secondary outcomes

Infant outcomes were skilful, with few babies having a low Apgar score at 5 minutes or evidence of metabolic acidosis. Overall, nigh 12% of babies required resuscitation at nativity (tabular array 4⇑).

Maternal satisfaction in labour was similar between the two groups (table 5⇓); however, only half of the women reported being able to move every bit much as they wanted. Few agin events occurred. Mothers experienced dizziness (n=29 in the upright group and n=21 in the lying down grouping), postpartum haemorrhage (n=one in each group), seizure (n=2 in lying downward group), stroke (n=1 in the lying down grouping), maternal infection (n=i in the upright group and n=2 in the lying down group), dural tap (n=ane in the upright group), and postpartum haemorrhage with retained placenta (n=1 in the upright group). Of infants born to mothers in the upright group one was a stillbirth, one experienced birth trauma, i had cardiorespiratory plummet i hr post birth, and ane had suspected Erb'due south palsy.

Table 5

Maternal satisfaction. Values are numbers (percentages) unless stated otherwise

The prespecified subgroup analyses showed no evidence of heterogeneity betwixt any of the prespecified subgroups for the principal effect of spontaneous vaginal nascence (fig 3⇓).

Fig 3 Wood plot showing results of subgroup analyses for spontaneous vaginal birth. *All models adjust for eye as a random effect. †Diagnosis of filibuster before written report entry requiring syntocinon

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No prove of whatsoever differences between the groups was establish for incidence or severity of urinary incontinence, faecal incontinence, constipation, haemorrhoids or dyspareunia, general wellbeing, or wellness related quality of life (table half dozen⇓). This finding was unchanged in a sensitivity analysis where women were excluded if they were significant or had another child by the time of the i year follow-up (table 7⇓). Similarly, there was no show of a difference in the incidence of diagnosed cerebral palsy or severe neurodevelopmental delay in any of the infants at one year: major morbidity was experienced past 0.one% (1/950) in the upright group and 0.4% (four/942) in the lying downwardly group, with a risk ratio adjusted for heart equally a random effect of 0.25 (99% conviction interval 0.01 to 4.twoscore). The response charge per unit to the one year follow-upwards was 61.ii% (1892/3093). In that location were differences betwixt women who responded and those who did non respond, with responders tending to be slightly older, white, and from less deprived areas, and more likely to have an instrumental vaginal birth with prove of perineal trauma. Nevertheless, there were no apparent differences in the two randomised groups in their response rates or characteristics, suggesting no major biases in the comparison between the two groups (table viii⇓).

Table 6

Secondary maternal and infant outcomes up to i year. Values are numbers (percentages) unless stated otherwise

Table 7

Sensitivity analysis: one year maternal outcomes excluding women who had another child or were pregnant at time of cess. Values are numbers (percentages) unless stated otherwise

Table 8

Generalisability of women followed-up. Values are numbers (percentages) unless stated otherwise

Discussion

Evidence from this randomised controlled trial indicates that a policy of adopting a lying down position in the second stage of labour in women having their first infant with epidural analgesia increases the chances of a spontaneous vaginal birth (number needed to treat 17 women (95% confidence interval eleven to forty) to achieve one boosted spontaneous vaginal nativity). No disadvantages were credible to curt or longer term outcomes for mother or baby.

Strengths and limitations of this written report

As with all pragmatic trials, this study has limitations. The incidence of spontaneous vaginal birth in this population of women was lower than anticipated. Our original sample size calculation was based on a spontaneous vaginal nascency rate of approximately 55% in the control group.4 This trend towards higher rates of intervention in the second stage of labour—both instrumental delivery and caesarean section—has been previously noted.xv Instrumental commitment is associated with high rates of perineal trauma and subsequent morbidity, particularly faecal incontinence.

With an intervention such as this, masking is incommunicable, so the results may be influenced by the women'due south and the midwives' perceptions of the unlike positions in their power to achieve a spontaneous vaginal birth. Given that existing guidance from the National Establish for Health and Care Excellence recommends that women with an epidural should be encouraged to prefer any upright position they observe comfortable, it is possibly not surprising that adherence was lower in the lying downwardly grouping than in the upright group, causing a possible dilution of the handling effect.xvi Attributable to the unmasked nature of the intervention and the possibility that some midwives may firmly believe that the upright position is preferable, we might as well expect the trial results to advise an comeback in spontaneous vaginal birth with an upright position. The finding that the lying downwards position increased the chances of achieving a spontaneous vaginal birth suggests that this potential bias was either absent or minimal in its impact, or that the do good of the lying downwardly position may be even greater in leading to a spontaneous vaginal birth.

We can merely speculate about the machinery by which lying down increases the chance of a spontaneous vaginal nascence in nulliparous women with a low dose epidural. Nosotros have no direct measurements of the density of the epidural cake in the ii positions nor the level of the block as second stage progressed. It is possible that women in the upright position acquired a denser block around the birth canal resulting from the potential effects of posture and gravity on the spread of drugs within the epidural space, which could in plow accept fabricated expulsive efforts less effective. Still, the similarity of drug doses throughout the second stage of labour used in each group would suggest that this is unlikely. Women in the upright grouping, who may have been sitting, might have had a restricted pelvic outlet because of pressure on their coccyx or considering of venous obstacle causing lower genital tract oedema and obstacle of the soft tissues of the pelvic outlet. In improver, information technology is possible that the lying down group, by easing pressure of the fetal head on the pelvis had improved uterine blood flow and therefore improved uterine activity. This would suggest a departure in the risk of operative delivery associated with failure to progress. The distribution of indications for operative delivery, however, appeared to be the same in either group. In addition, footling difference was constitute in the utilize of oxytocin considering of delay in labour progress afterward trial entry.

In that location was a proffer that perineal trauma might as well have been decreased in the lying down group, although differences in these inter-related outcomes were not statistically pregnant at our prespecified 1% level. A contempo large observational study from Sweden, using routine information, found a statistically significant lower incidence of obstetric anal sphincter injury in women in the lateral position compared with the sitting grouping (run a risk ratio 0.79, 95% confidence interval 0.68 to 0.92).17 This result is like to our finding (adjusted risk ratio 0.79, 95% confidence interval 0.59 to one.04). Given that an increment in spontaneous vaginal births results in a decrease in operative births, it would follow that perineal trauma would be increased in the group with more instrumental deliveries. There is besides a suggestion (non statistically significant at the 1% level) that instrumental vaginal delivery might be increased in the upright group in this trial.

In this trial the lack of any difference on longer term outcomes such as faecal incontinence is of interest. The existing observation that instrumental vaginal commitment is associated with an increased risk of faecal incontinence is robust.18192021 The likely explanation in this trial is that the difference between the randomised groups of women in their adventure of spontaneous vaginal nascence was relatively small, meaning that the impact of dissimilar modes of nativity on long term outcomes is diluted.

Comparison with other studies

The existing evidence from randomised controlled trials is inconclusive. The Cochrane review7 contains five trials including a total of 879 women, with clinical heterogeneity between the trials. For example, some women were actively encouraged to walk, and others were supported in a sitting position in the upright grouping. In the recumbent group, some trials had women sitting and others had women in a lateral position. This trial adds a farther 3000 women to this show, with clearly defined comparison groups. When these data are added to the three most comparable trials—that is, those where women were allocated upright versus lying down positions (every bit opposed to semi-recumbent positions), then the sum of the prove strongly supports a lying downwards position to achieve a spontaneous vaginal nativity (upright versus lying down meta-assay odds ratio 0.80, 95% conviction interval 0.seventy to 0.92).

Conclusions and policy implications

This study provides prove that adopting a lying down position in the second stage of labour results in more spontaneous vaginal births in nulliparous women with epidural analgesia, with no apparent disadvantages for short or longer term outcomes for mother or baby. The intervention seems to be easy to prefer and is cost gratis. This bear witness volition permit pregnant women, in consultation with their healthcare providers, to make informed choices about their position in the 2d stage of labour.

The results from this trial utilize to nulliparous women in the second stage of labour with epidural analgesia. Information technology is unclear what the findings mean for multiparous women in labour with an epidural. However, women should exist offered the choice of adopting a lying down position in the second stage until proven otherwise. We too practice not know what these results mean for women of all parities without an epidural. Given the variable quality of existing randomised trials of position in the second stage of labour in women without an epidural,6 the results of the BUMPES trial strongly back up the development of a similar large pragmatic trial with clear operational descriptions of position in women in labour without epidural analgesia.

What is already know on this topic

Women who use an epidural for pain relief in labour are more likely to have an instrumental vaginal birth than those who utilize other methods of analgesia
Maternal position in the 2d stage of labour (afterwards the cervix is fully dilated) may bear on the incidence of spontaneous vaginal nascency, but the existing evidence from randomised controlled trials is unclear

What this study adds

In nulliparous women in labour at term with an epidural and a singleton fetus, a policy of adopting a lying downwards position (left or right lateral) during the 2nd stage of labour increases the hazard of spontaneous vaginal nativity compared with a policy of adopting an upright position
There were no agin consequences of this approach for female parent or infant in the short term, or at 12 months post nascency

Footnotes

We thank the women who agreed to join the trial.

Writing committee: Debra Bick, professor of evidence based midwifery practise, Kings College London; Annette Briley, consultant midwife, Guys and St Thomas's NHS Foundation Trust; Peter Brocklehurst, professor of women's wellness, UCL, and professor of women's wellness, director of Birmingham Clinical Trials Unit of measurement, University of Birmingham; Pollyanna Hardy, senior trials statistician, Academy of Oxford; Edmund Juszczak, manager, NPEU Clinical Trials Unit, University of Oxford; Lynn Lynch, midwifery lecturer, Cardiff University; Christine MacArthur, professor of maternal and kid epidemiology, University of Birmingham; Phillip Moore, consultant anaesthetist, University Infirmary Birmingham NHS Trust; Mary Nolan, professor of perinatal education, University of Worcester; Oliver Rivero-Arias, senior health economist, University of Oxford; Julia Sanders, consultant midwife, Cardiff Academy, and reader in midwifery, Cardiff & Vale Health Board; Andrew Shennan, professor of obstetrics, Kings Higher London; Matt Wilson, consultant in obstetric anaesthesia, Sheffield Teaching Hospital, and senior lecturer in anaesthesia, Academy of Sheffield.
Contributors: All authors contributed as to the development of the protocol and management and undertaking of the trial. PH and OR-A did the analyses. PB wrote the outset draft of the manuscript and revised it with input from the writing committee. All authors read and canonical the final manuscript. Atomic number 82 acts as the guarantor.
Funding: This project was funded by the National Plant for Health Research (NIHR) wellness technology assessment (HTA) plan (projection No 08.22.02). This report presents contained research commissioned by the NIHR. The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the National Wellness Service, the NIHR, Medical Research Council, CCF, NETSCC, the HTA programme, or the Department of Health. CM was function funded by the Collaboration for Leadership in Practical Wellness Inquiry and Care (CLAHRC) Due west Midlands, and DB and AB by CLAHRC South London.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support from the NIHR HTA programme for the submitted work; no financial relationships with whatever organisations that might have an involvement in the submitted piece of work in the previous iii years; no other relationships or activities that could announced to have influenced the submitted piece of work.
Upstanding approval: This study was canonical past the National Research Ethics Service—Oxfordshire enquiry ethics commission B (reference No 09/H0605/114). The study protocol can exist accessed at www.ucl.ac.uk/cctu/researchareas/womenshealth/bumpes/documents/protocolv5.
Data sharing: Requests for access to information from the BUMPES trial should exist addressed to the corresponding author.
Transparency: The lead author (Pb) affirms that this manuscript is an honest, accurate, and transparent account of the study existence reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

This is an Open Access commodity distributed in accordance with the terms of the Creative Commons Attribution (CC By four.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial apply, provided the original work is properly cited. Meet: http://creativecommons.org/licenses/by/four.0/.

References

↵
↵
↵
↵

Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery: a randomised controlled trial. Lancet 2001;359:19-23. doi:10.1016/S0140-6736(00)05251-X pmid:11454372.
↵

Liu EH, Sia AT. Rates of caesarean section and instrumental vaginal delivery in nulliparous women after depression concentration epidural infusions or opioid analgesia: systematic review. BMJ 2004;359:1410. doi:ten.1136/bmj.38097.590810.7C pmid:15169744.
↵
↵
↵

Roberts CL, Algert CS, Cameron CA, Torvaldsen S. A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia. Acta Obstet Gynecol Scand 2005;359:794-8. doi:10.1111/j.0001-6349.2005.00786.x pmid:16026407.
↵

Downe Due south, Gerrett D, Renfrew MJ. A prospective randomised trial on the effect of position in the passive 2d stage of labour on birth outcome in nulliparous women using epidural analgesia. Midwifery 2004;359:157-68. doi:10.1016/S0266-6138(03)00052-4 pmid:15177859.
↵
↵
↵

Jenkinson C, Layte R. Development and testing of the U.k. SF-12 (short form wellness survey). J Health Serv Res Policy 1997;359:14-8.pmid:10180648.
↵

Pocock SJ, McMurray JJV, Collier TJ. Statistical Controversies in Reporting of Clinical Trials: Part 2 of a 4-Role Series on Statistics for Clinical Trials. J Am Coll Cardiol 2015;359:2648-62. doi:ten.1016/j.jacc.2015.10.023 pmid:26670066.
↵
↵
↵

National Collaborating Middle for Women's and Children's Health (UK). Intrapartum care for salubrious women and babies. London: RCOG Press; 2022 Dec. (NICE Clinical Guidelines, No 190.) http://www.ncbi.nih.gov/books/NBK49388/ 2007.
↵

Elvander C, Ahlberg M, Thies-Lagergren L, Cnattingius Due south, Stephansson O. Birth position and obstetric anal sphincter injury: a population-based written report of 113 000 spontaneous births. BMC Pregnancy Childbirth 2015;359:252. doi:10.1186/s12884-015-0689-7. pmid:26453177.
↵
↵
↵
↵

MacArthur C, Wilson D, Herbison P, et al. ProLong study group. Faecal incontinence persisting after childbirth: a 12 year longitudinal study. BJOG 2013;359:169-78, word 178-9. doi:ten.1111/1471-0528.12039 pmid:23190303.

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Source: https://www.bmj.com/content/359/bmj.j4471