Results of the BUMPES Trial: Sitting Up or Lying Down to Promote Vaginal Delivery with an Epidural in the 2nd Stage of Labor?

BACKGROUND AND PURPOSE:

• Recent Cochrane Review did not demonstrate a difference between upright or recumbent when assessing the chance of a spontaneous vaginal birth in women with epidural anesthesia
• Brockehurst et al. (BMJ, 2017) sought to determine whether the  upright position  during the second stage of labor increases the chance of spontaneous vaginal birth in women with a low-dose epidural

METHODS:

• Birth in the Upright Maternal Position with Epidural in Second stage (BUMPES) Trial
• Multicenter randomized controlled trial (RCT)
• Inclusion Criteria
  • ≥ 16 years, ≥ 37 weeks gestation, nulliparous, singleton cephalic presentation, and intended to have a spontaneous vaginal birth
  • 2^nd stage with low dose epidual in situ
• Subjects were assigned to the following groups:
  • Upright position
    • Maintain pelvis in as vertical a plane as possible
    • Walking, kneeling, sitting etc. all acceptable
  • Lying down position
    • Up to 30 degrees inclination
  • Groups were stratified by center
    • Blinding of participants or clinicians not possible
  • Primary outcome was spontaneous vaginal birth
  • Secondary outcomes were
    • mode of birth, perineal trauma, infant Apgar score <4 at 5 minutes, admission to a neonatal unit
    • longer term outcomes included maternal physical and psychological health, incontinence, and infant gross developmental delay

RESULTS:

• 1,556 participants were in the upright group and 1,537 in the lying down group
• Primary Outcome
  • There were significantly fewer spontaneous vaginal births in the upright group (35.2%) vs the lying down group (41.1%) with adjusted risk ratio (RR) 0.86 (95% CI 0.78 to 0.94)
• Secondary Outcomes
  • No evidence of difference for most of the secondary maternal, neonatal, or longer term outcomes including
    • Vaginal delivery, obstetric anal sphincter injury, infant Apgar score <4 at five minutes and maternal fecal incontinence at one year

CONCLUSION:

• There is a 5.9% absolute increase in the chance of spontaneous vaginal birth in the lying down group
• Authors recognize limitations of the study
  • Inability to mask
  • Unless there is an indication to do otherwise, guidance and practice promote women using any position they find more comfortable and may have resulted in superior adherence in the upright group
• No obvious mechanism to explain findings
• When adding this current cohort of approximately 3,000 well randomized women to previous data, sum of evidence strengthens findings in this paper
  • Combining present results with previous data, odds ratio of upright vs lying down is 0.80 (95% CI 0.70 to 0.92)

Learn More – Primary Sources:

Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomized controlled trial