Informed Choice and the BRAIN Acronym

I vary my prenatal visit topics depending on my client's experience and knowledge, but one of the things I talk about with every doula client is Informed Choice and Informed Consent. Specifically, we discuss what it will be like to exercise their right to informed choice during the sometimes highly emotional experience of pregnancy and childbirth in a medicalized setting where informed consent is not always practiced (sad, but true).  An excellent tool to use to talk about this topic and help clients see what this looks like, especially during labor, is the BRAIN acronym. 

Use Your BRAIN! 

In most instances, there is time to discuss every treatment or procedure with the care provider. This includes the nurses, too, not just the doctor or midwife. The reason this is a great tool is because everything that happens to a patient should include an informed choice, which includes both the option of informed consent and informed refusal. Yes, the doctor has been to medical school, but that doesn't mean that everything she says or proscribes is based on scientific evidence, or that it is your only option.

Benefits - What are the benefits of this procedure? How will this help me/my baby/my labor?

Risks - What are the risks of this procedure? How might this negatively affect me/baby/labor?

Alternatives - Are there alternatives to this procedure? Are there other options?

Intuition - What is my gut feeling about this?

Need Time, or Nothing - Can I delay this procedure and take some time to think about it/Discuss it with my partner? What will happen if I choose to do nothing for now?

The BRAIN acronym and Informed Consent exercise may seem obvious, but for many people, especially pregnant and laboring women, it doesn't always occur. Many people don't realize that they have the right to ask these questions or even to refuse certain procedures when they are being told they "have" to by a physician with authoritative knowledge. There is a social power play going on, and it is going on while a woman is nervous for her and her baby's health.

I recently had a client use the BRAIN acronym for informed consent/refusal that I had taught her and her partner! Her doctor started talking about induction at her 40 week prenatal visit, and then scheduled some dates for her at the hospital, even though he told her at 2 check-ups that she and baby were doing well. She felt very nervous about it, but also nervous because of the way the doctor talked about "what could happen" to the baby. So she went home and talked to her partner about the Benefits, Risks, Alternatives, Intuition, and Need Time aspects of the decision to induce. Then she called me and told me that the only benefit they could think of was seeing the baby sooner! Which wasn't enough to make them feel comfortable with inducing, so they decided to tell the doctor they'd like to wait until 42 weeks. So awesome!

• No person should give you a pelvic exam or manipulate your cervix without your prior consent.
• No person should pressure you into attempting induction unless it is medically necessary.
• No person should pressure you to dilate faster for his or her own convenience.
• No person should break your water or cut your perineum without consulting with you first and gaining your permission.
• You have the right to refuse a course of treatment that you feel is not in your or your baby’s best interest.
• No person should rush you to make a decision.

These things are true, and childbirth educators and doulas say these sort of things all the time, but they still happen. I see them happen. So it is an important thing to pass on to our clients -  YOU HAVE A RIGHT TO CONSENT TO AND REFUSE ANYTHING THAT INTERFERES WITH YOUR BODY OR THE BODY OF YOUR CHILD.

There are some great informed consent role plays out there, where mom and partner can practice asserting their rights. I really like these (via Prep for Birth), because these are very difficult situations that almost every woman birthing in a hospital will find herself in:

You are laboring along slow but sure. Early labor is taking awhile. Your contractions change and seem stronger. You go to the hospital and are 5 centimeters. Baby looks good on the monitoring in triage, so you are assigned a room. The labor and delivery nurse would like you to stay in bed and not move around or get into the shower/tub. That is ALL you want to do.

What would you do?

 Hopefully, you would use your BRAIN! Let's practice:

B: What are the Benefits of staying in the bed? Well, your labor has been normal and the baby looked healthy on the monitor. Your body is telling you that you would be more comfortable moving around. So why would the nurse ask that of you? There are benefits for the nurse - he/she can keep you securely hooked up to the electronic fetal monitor, the blood pressure cuff, possibly an IV, and all the other gadgets being used to record your vitals. That way she can leave the room to do other things but you are still being "monitored" by the equipment. The nurse has also been told in training that birth must occur in the bed and that the monitor is the best and only way to detect fetal stress, which in her experience happens all the time.

R: What are the Risks associated with staying in bed? Well, you would be extremely uncomfortable the whole time, especially if getting out is all you want to do. Another risk is that staying in bed may make your labor more painful and possibly slower. Moving in response to labor contractions and change of positions makes use of gravity and changes the shape of your pelvis, helping baby make his/her way down. The freedom to move and to use pain coping techniques like the shower gives you an increased sense of control and lessens your anxiety. (For more about the proven benefits of movement during labor, click here).

A: Are there alternatives to this procedure? Can we get more information about why the nurse wants you to stay in bed? If its to keep the baby on the monitor, you can request intermittent monitoring (every 45 minutes or so)? Or maybe something that is portable, like a fetoscope or a telemetry unit, and that way you can even get into the shower. If you have done your research, or if the nurse/doctor does theirs, you will know that routine continuous EFM provides no benefit for babies and increases the risk of cesarean for mothers.

I: What is my Intuition telling me? Well, that's easy - its I WANT TO MOVE! 

N: Its ok to Need some time to think about it. You might choose to stay on the monitor for a bit and see if you can get comfortable with that. Or, after you gathered all the information you can from your nurse and or doctor on the benefits, risks, and possible alternatives, you just want a few minutes to talk to your partner and your doula about what you're thinking and feeling. There is no rush to decide.

Here's another scenario:

You have been assured that after your push out your baby, he will be placed right on your belly or chest for assessments even if he needs oxygen without separating you two. After you birth your baby, he is making good effort to breathe, is vocalizing, and his color is just right. The baby nurse wants to take him right away. You ask her to do all his assessments on you and she says no and without your consent takes him off to the warmer.

What would you do?

(Some may recognize this in a different form - BRAND. I like BRAIN better because it includes Intuition, and also because the "Nothing" and the "Delay" of BRAND seem too similar to me, and are encompassed well under "Need time.)