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.
CORE (COnnecting REpositories)
CORE (COnnecting REpositories)