Supporting you to make a decision

The “BRAIN” decision-making tool can help in deciding whether to proceed with induction of labour: - Benefits - What are the benefits? - Risks - What are the risks? - Alternatives - What are the alternatives? - Intuition - How do you feel? What is your gut feeling? - Nothing - Do nothing, wait for labour to start. The decision to have an induction of labour is entirely up to you. You can choose not to accept an induction of labour. Below are some possible options for after your due date (40 weeks): At 41 weeks (1 week overdue), 83 in 100 women/birthing women have spontaneous labours by this gestational age. If you have not gone into spontaneous labour, your team will offer to plan a date for an induction. This is due to increasing chances of: caesarean birth, stillbirth, paediatric support needed for your baby and neonatal death. You can choose to wait for spontaneous labour if you wish. Up to 42 weeks, 99 in 100 women/birthing people have spontaneous labours by this gestational age. If you wish to wait for spontaneous labour beyond 42 weeks - extra monitoring may be offered, but it cannot always predict or prevent stillbirth or other complications. You can choose not have an induction of labour. The alternatives are spontaneous labour and vaginal birth or a caesarean birth. How you feel and any gut feelings are important. You can speak to your midwife at any point during an induction if you feel uneasy about something. You can do nothing and wait for labour to come on if you wish.

Benefits to Mother: - Feeling an increased sense of control when planning your birth. - Reduces your chance of developing late onset pre-eclampsia (>39 weeks). - Reduces your chance of an unplanned/emergency caesarean birth by approximately 10% compared to waiting for your labour to start until 41 weeks. Benefits to Baby: - Baby is more likely to be born with a better APGAR score (quick health check of baby). - Reduces the likelihood of stillbirth late in pregnancy. - Reduces the risk of your baby needing admission to the neonatal intensive care unit (NICU). - Reduces the likelihood of neonatal death. - If you’ve been told that your baby is large-for-dates, the chances of their shoulders getting stuck at the time of birth (shoulder dystocia) may be reduced. Inducing labour prevents one perinatal death for roughly every 544 women who have it. Perinatal death means inside the womb and up to first week of life. Benefits of oxytocin use: - Oxytocin use is generally considered safe for mother and baby. - It has not been shown to increase the uptake of epidurals. Benefits in specific circumstances: - If you have had a previous caesarean birth, mechanical methods (using a foley or Cook’s catheter) are associated with a lower risk of your scar coming apart (rupturing). - Induction may be more beneficial for those whom stillbirth rates are higher for example; Those from a minority ethnic background, those who live in more deprived areas of the UK or your baby has fetal growth restriction. - 5 in 100 less women with a BMI >30kg/m2 will have an unplanned/emergency caesarean birth if they are induced between 39-40 weeks compared to waiting for spontaneous labour to begin.

Key considerations for mothers: • Induction is a medical intervention and therefore monitoring and examinations are required. • May limit the choice of birth location and the use of birthing pools. • Some women/birthing parents report they found induced labour more painful. • Outpatient induction offers less frequent monitoring and may increase the chance of undetected complications. . You may need an instrumental birth (but this risk is no higher than physiological labour). • Induction may not lead to active labour • You may have heavy bleeding after birth (postpartum haemorrhage). Chances depend on whether you have medication (oxytocin) after your baby is born. • Infection: your chance may be higher if your labour is longer than average, or your waters break early in the induction. • Cervical ripening methods (membrane sweeping, medications, mechanical methods) can be painful to insert/carry out. • Increased chance of significant pelvic floor injury (perineal tear) if your baby is large for dates or you have an instrumental birth. • If you have had a previous caesarean birth there is a higher chance of uterine rupture and unplanned or emergency caesarean birth if you are induced: 4 in 1000 (induction of labour) vs 2 in 1000 (spontaneous labour) have a uterine rupture and 35 in 100 (induction of labour) vs 25 in 100 (spontaneous labour) have an unplanned or emergency caesarean birth. Risks for the baby: • Contractions becoming too frequent with the use of cervical ripening methods or the oxytocin drip may cause fetal distress, this can usually be managed. • Delaying starting the oxytocin drip may mean that your labour takes longer and there may be an increased risk of your baby developing an infection. Possible delays: • Induction may be delayed due to hospital staffing or demand. Emergency situations: Depending on your individual situation, there is a small risk of certain serious complications, which may lead to an emergency caesarean birth or other procedures. • Cord prolapse – when we break your waters the baby's umbilical cord may fall into your vagina. • Uterine rupture – particularly if you’ve had a previous caesarean birth or uterine surgery. • Shoulder dystocia- where baby's shoulders get stuck during birth. • Bleeding from the placenta (abruption). Red flags: Women should alert medical staff if they experience significant pain, bleeding, or reduced fetal movements during induction.