Over the past year, in my practice as an independent and community midwife, I have become more and more aware of the acronym B.R.A.I.N. as a tool for pregnant and birthing women. It is beneficial to the women themselves as well as their carers, supporters and advisors. 
Decision-making in pregnancy and labour can be a fraught process, even to women who have a thorough knowledge of what is happening to them and their baby. Using BRAIN as an aid in this decision-making may not only make that process easier, but it is empowering and clarifies to all that you are the one in control of your pregnancy and birth.
To demonstrate how using this tool can clarify and inform decision-making, let’s look at a scenario:
Maddy is in early labour with her first child. She has had a long latent phase, and after being on the labour ward for eight hours, she is still only 2cm dilated. There are no signs the baby is in distress, the heart rate has been listened to intermittently without any concerns. Maddy is tired, she hasn’t been sleeping well and has not closed her eyes for about 20 hours.
The obstetrician does his labour ward rounds and, after reviewing Maddy’s notes, he recommends that Maddy should have her waters broken to help speed things along. Maddy and her partner have attended antenatal classes and have heard about the “cascade of intervention”, and they are fearful that this action could lead to further interference. But equally, Maddy is tired, and even if things really get going now, the birth could be many hours off, with lots of hard work to come. She decides to use her BRAIN.
B is for Benefits
What are the benefits of this course of action? 
Labour may be stimulated to increase in intensity, as the baby’s head directly on the cervix may be more effective in dilating the cervix.
R is for Risks
What are the risks associated with this action?  The cascade of intervention may kick in (see under 'I'). Once the membranes have been broken, there is a risk of bacteria setting up an infection in the baby, so time becomes more of an issue.
A is for Alternatives
Are there alternatives to this course of action? 
Going for a walk may encourage contractions, and getting into different positions so that the uterus is more efficient can also help. Having something to eat to keep blood sugars normal may provide more energy for the uterus. Getting some sleep would definitely help Maddy, and maybe some analgesia would enable her to snatch a few hours rest.
I is for Implications
What are the implications of this course of action? Cascade of intervention? 
If the cervix does not start dilating within a few hours of the ARM, syntocinon - an artificial hormone given via a drip - will be recommended. Continuous foetal heart monitoring is needed if syntocinon is used, because the contractions and their effect on the baby need to be assessed, and adjustments made if necessary.
Maddy would have either transducer on her abdomen or a clip directly on baby’s head to monitor the heartbeat, and these are connected to a bulky machine that produces a print-out of the heart and the contractions. Being mobile with a machine attached is quite difficult, and Maddy will probably end up lying on a bed. She knows this can make contractions less effective and often more painful.
She may not cope without pain relief and may have to have an epidural in order to deal with the stronger contractions from the hormone drip as well as being unable to position herself in the best way. This is not the birth she envisaged: on her back, wired up to a machine, numb from the waist down. She has heard that this more often than not leads to the baby becoming distressed and needing a fast delivery by forceps or caesarean section.
N is for Nothing
What if we do nothing?
Maybe waiting for a few hours will be enough time for Maddy’s own natural oxytocin to stimulate the contractions. If the baby remains well, does it matter that labour is taking longer than expected?
It is possible that the contractions will peter out, and that Maddy and her partner can go home to bed. They may then come back when labour restarts, which it is more likely to do when Maddy is rested and in her own environment or ‘nest’.
Using Maddys BRAIN won't solve everything for her, but it may clarify her options and the risks and benefits of alternative actions to the obstetrician’s suggestion. Thinking clearly when stressed and tired is difficult; utilising analytical aids such as BRAIN can give you that extra oomph you need, and give you back your control.
Happy birthing!
Midwifery Expert 



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