Content area
Full text
Introduction
As the most effective form of pain relief in labour, epidural analgesia is chosen by approximately 30% of women in the UK each year, and this proportion has remained relatively stable over the past decade. 1 2 Epidural analgesia leads to prolongation of the second stage of labour (from full dilation of the cervix until birth) and an increased risk of instrumental vaginal delivery. However, this evidence comes mostly from trials that used epidural techniques which cause dense neuraxial blockade. 3 Epidurals that use low dose local anaesthetic in combination with opioids result in a lower risk of instrumental vaginal delivery, but the rate of such delivery is still higher than among women with no epidural. 4 5 Maternal position during the second stage of labour has been suggested to affect the risk 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, after 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 risk ratio of operative birth (caesarean section or instrumental vaginal delivery) reported in the five included trials, comprising 879 women in total, was 0.97 (95% confidence interval 0.76 to 1.25). 7 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. 8 9
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 chance of spontaneous vaginal birth, compared with lying down.
Methods
Study design and participants
This was a pragmatic randomised controlled trial carried out in UK maternity units. Women were eligible...