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

BMJ 2017; 359 doi: (Published 18 October 2017) Cite this as: BMJ 2017;359:j4471
  1. The Epidural and Position Trial Collaborative Group
  1. Correspondence to: Peter Brocklehurst p.brocklehurst{at}
  • Accepted 7 September 2017


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

Design Multicentre pragmatic individually randomised controlled trial.

Setting 41 UK hospital labour wards.

Participants 3093 nulliparous women aged 16 or older, at term with a singleton cephalic presentation and in the second stage 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 centre, with no masking of participants or clinicians to the trial interventions.

Main outcome measures The primary outcome was spontaneous vaginal birth. Women were analysed in the groups into which they were randomly allocated, regardless of position recorded at any 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 birth, perineal trauma, infant Apgar score <4 at five minutes, admission to a neonatal unit, and longer term included maternal physical and psychological health, incontinence, and infant gross developmental delay.

Results Between 4 October 2010 and 31 January 2014, 3236 women were randomised and 3093 (95.6%) 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 chance of spontaneous vaginal birth in the lying down group (number needed to treat 17, 95% confidence interval 11 to 40). No evidence of differences was found for most of the secondary maternal, neonatal, or longer term outcomes including instrumental vaginal delivery (adjusted risk ratio 1.08, 99% confidence interval 0.99 to 1.18), obstetric anal sphincter injury (1.27, 0.88 to 1.84), infant Apgar score <4 at five minutes (0.66, 0.06 to 6.88), and maternal faecal incontinence at one year (1.18, 0.61 to 2.28).

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 short or longer term outcomes for mother or baby.

Trial registration Current Controlled Trials ISRCTN35706297.


  • We thank the women who agreed to join the trial.

    Writing committee: Debra Bick, professor of evidence based midwifery practice, Kings College London; Annette Briley, consultant midwife, Guys and St Thomas’s NHS Foundation Trust; Peter Brocklehurst, professor of women’s health, UCL, and professor of women’s health, director of Birmingham Clinical Trials Unit, University of Birmingham; Pollyanna Hardy, senior trials statistician, University of Oxford; Edmund Juszczak, director, NPEU Clinical Trials Unit, University of Oxford; Lynn Lynch, midwifery lecturer, Cardiff University; Christine MacArthur, professor of maternal and child epidemiology, University of Birmingham; Phillip Moore, consultant anaesthetist, University Hospital 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 University, and reader in midwifery, Cardiff & Vale Health Board; Andrew Shennan, professor of obstetrics, Kings College London; Matt Wilson, consultant in obstetric anaesthesia, Sheffield Teaching Hospital, and senior lecturer in anaesthesia, University of Sheffield.

  • Contributors: All authors contributed equally to the development of the protocol and management and undertaking of the trial. PH and OR-A did the analyses. PB wrote the first draft of the manuscript and revised it with input from the writing committee. All authors read and approved the final manuscript. PB acts as the guarantor.

  • Funding: This project was funded by the National Institute for Health Research (NIHR) health technology assessment (HTA) programme (project No 08.22.02). This report presents independent 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 Health Service, the NIHR, Medical Research Council, CCF, NETSCC, the HTA programme, or the Department of Health. CM was part funded by the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands, and DB and AB by CLAHRC South London.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: support from the NIHR HTA programme for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the National Research Ethics Service—Oxfordshire research ethics committee B (reference No 09/H0605/114). The study protocol can be accessed at

  • Data sharing: Requests for access to data from the BUMPES trial should be addressed to the corresponding author.

  • Transparency: The lead author (PB) affirms that this manuscript is an honest, accurate, and transparent account of the study being 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.

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