Sunday, 24 November 2013

Freedom for birth

Peace on earth starts with birth.  Sounds cheesy?  Sounds daft?  Surely we don't need to worry about women's rights in childbirth?  Or persecution of midwives?  Our modern obstetrics run maternity care gives us the best outcomes and women don't need to worry any more, right? Wrong.

Midwives are being persecuted for supporting women's choices, and for giving women's choices.  The Albany midwifery practice was shut down and the senior midwife suspended, despite a better safety record than the local maternity unit and for incredible outcomes for women and babies - 99% knew the midwife who attended them at birth, and for 98% of them it was their own midwife; 40% gave birth at home; over 60% gave birth without even needing gas and air, they were so supported and prepared.  After more than three years the senior midwife has been exonerated, just this summer.

This isn't the only case in the UK.

Over in Ireland one woman died because she wasn't allowed to end the pregnancy of the very sick baby inside her.  Another was denied, in court, a vaginal birth after caesarean. She came to the UK and had her baby last month.

Many women are told 'you must' have a caesarean for a breech baby; 'you're not allowed' to go past 42 weeks; 'you can't' have a home birth if its your first baby/no midwives available/high bmi etc.  None of which are true.

Why does it matter?  Babies only get one birth.  Mothers will be making decisions for their babies till they are eighteen.  They should be empowered from the beginning.  Birth does matter.  Birth works best undisturbed.  This leads to better outcomes for babies. The obstetric led model of maternity care does not get it right.  We wouldn't treat our cats and dogs in birth as we do women.  Birth sets up a mother for the post natal period.  To be happy and confident, or confused and scarred.  I have supported women who felt raped by their midwives/obstetricians as they lay naked on the bed with legs in stirrups and arms and hands and instruments entering their vagina, while they shouted 'stop' 'no'. Others so traumatised by how the birth went, and mostly, how they were treated, that it takes years before they are ready to be pregnant again, if ever.

This film highlights human rights in childbirth.  It mostly follows the case of the Hungarian obstetrician, Agnes Gereb, who, unable by Hungarian law to support women at home births, retrained to be a midwife and then was taken to court and is currently under house arrest.  A woman in premature labour had come into her clinic.  Agnes Gereb had taken the women to hospital and the baby died.  The parents know it was not Agnes Gereb's fault.  But it was enough for the authorities to arrest her.  See her powerful story, and those of women and midwives around the world.  Court ordered caesareans in the USA.  Woman denied home birth in Netherlands.  Plus hear wonderful testimony from famous midwives, obstetricians and activists at the first international conference on human rights in childbirth.  Michel Odent; Ina May Gaskin, Sheila Kitzinger, Beverley Beech, Professor Lesley Page, President of the Royal College of Midwives and Cathy Warwick, general secretary of the Royal College of Midwives.

One inspiring film; many people starting a birth revolution.

Wednesday, 2 January 2013

Let your hormones be in the driving seat in labour

Ok, hormones. Giving birth is regulated by the autonomic nervous system. This is controlled by the most primitive part of our brain, sometimes called ‘the reptilian brain’. The autonomic nervous system controls our basic functions: breathing, heart rate, body temperature, digestion, excretion – and giving birth. The autonomic nervous system has two modes of function – the sympathetic and the parasympathetic systems.

In normal daily life, especially when at rest, the parasympathetic system is to the fore and our heart rate is normal, breathing is normal, digestive functions and all the rest are normal. When we encounter stress the sympathetic system takes over as our body prepares for fight or flight. Our heart rate increases, we start to sweat, blood is diverted to our muscles and non-essential processes such as digestion and excretion shut or slow down. I am sure we can all think of times when we were under stress which made it difficult to eat or go to the loo - for example being in a strange place or insanitary conditions such as a festival.  Or becoming relaxed and everythings suddenly working: for example, arriving home from holiday the body relaxes and suddenly we need a poo!

Giving birth, because it is also controlled by the autonomic nervous system is similarly affected. We see this in wild animals – if they are disturbed or feel threatened in labour, labour stops until they feel safe again. Biologically this makes sense as it ensures both mother and baby survive. Interestingly, with animals in advanced labour who are threatened labour speeds up to get the baby out quickly so they can then get to safety.

You can reduce the effect of the sympathetic system by relaxing and breathing calmly and the body returns to normal state with parasympathetic system in the fore.

Birth is affected by three main hormones associated with the autonomic nervous system: oxytocin, endorphins and adrenaline. Oxytocin is like the accelerator of labour. The more oxytocin your body releases the stronger and closer the contractions become. Oxytocin causes the muscles to contract. It is also known as the love hormone as it is released during cuddles, stroking, kissing, nipple stimulation and sex. During climax it is oxytocin that causes ejaculation and vaginal contractions. The release of oxytocin is inhibited by the activation of the sympathetic system due to fear or embarrassment, and also by bright lights.

Endorphins are the body’s natural pain relief, a natural opiate. They are released when we are happy and feel loved, when we are massaged or we rub a part of our body to ease a pain. They are also released when we laugh. Their release is inhibited in the same ways as oxytocin. Where oxytocin was the accelerator, endorphins are the clutch. As oxytocin is released and contractions increase, the body releases endorphins which help you cope with the contractions. This then leads to more oxytocin being released, contractions increases in strength and length as labour goes up a gear. So it goes on: oxytocin is released, contractions increase, endorphins are released, the body copes, more oxytocin is released, contractions increase, endorphins are released, the body copes etc. By the end of labour the cocktail of oxytocin and endorphins creates a natural high. Davina McColl, the presenter, who confesses to using drugs in her past, described the high at the point of birth as the biggest high she had ever experienced. Both mother and baby’s brains are flooded which aids bonding, the contraction of the uterus and breastfeeding.

By contrast, the third hormone, adrenaline is released when the sympathetic system is to the fore. Adrenaline is the brake in this analogy. It is the release of adrenaline that causes labour to slow down or stop. Adrenaline is released when we are afraid, embarrassed, feel lack of control. Remember what happens to other mammals in labour? This happens to women too. It is very common for women who have been labouring well at home to find that their contractions slow or stop when they go to hospital as the adrenaline released by the excitement and anxiety.

Just to complete the analogy: the handbrake in labour is stimulation on the neocortex. The neocortex or fore brain is the most recent part of the brain and controls language and reason. In labour the more primitive part of the brain is in control and there is little activity in the neocortex. Stimulation of the neocortex by talking, or making decisions, wakes up the neocortex which then takes over control of the body resulting in stalled labour. Left undisturbed, women are in ‘labour land’, barely able to talk by the end, or understand speech.

The last hormone to be involved in labour is prolactin. This is released at birth and encourages the placenta to come away and milk to be made.

To put this knowledge into practise think about the following situations you might find yourself in.  What could you, or your birth partner do to restore or protect the flow of positive hormones, keep the parasympathetic system to the fore and reduce the impact on interference?

1. Labouring at home, sunlight streaming in, phone ringing, workmen drilling in the road.

2. Labouring well at home, go into hospital and contractions slow down, you’re told you’re not in proper labour and to go home.

3. You are worried about childbirth, about the baby being okay, about coping with the pain. Your partner has lots of worries about childbirth, about the baby being okay, about you being okay.

4. You are in a hospital room. The lights are bright, the sun is streaming in, you can hear the midwives’ phone ringing at their desk, there are workmen drilling in the car park.

5. Labouring well but every time you have a contraction midwife approaches and puts her hand on your belly and the contractions stops.

6. Labour has been going well and contractions were getting closer and stronger but now are slowing down. Your heart rate is up. You start to worry that everything is going to go wrong.

7. Labour has been going well and contractions were getting closer and stronger. You haven’t seen a midwife in ages and partner is getting anxious. You are picking up on his anxiety.

8. Midwives are talking to you about the time, about when you last went to the loo, or what time the consultant will be around, they are asking you to make decisions about colour of cord clamp or asking you about when you are going back to work.

9. You are on an electronic fetal monitor. Everything is fine but just hearing the beeps is making you anxious. You listen out for every one to check if baby is okay.

Drop me an email and I will discuss this further.  See the next blog post to get ideas too.

Saturday, 25 February 2012

Ten really important things about birth that noone tells you

1.             Having the continuous reassuring presence in labour of another woman, who has had a positive experience of birth herself (your mum, sister, friend, midwife, doula), seriously increases your chance of having a straightforward vaginal birth.  The government recommends all women be told this.

2.             Birth is an involuntary bodily function controlled by the autonomic nervous system, which also controls your breathing, digestion, going to the loo and other automatic functions over which you have very little control, except to stop or slow it down.  Labour will be easier, quicker and less painful if you feel safe and in control enough to let go and let it happen, letting the hormones flow and the muscles work. 

3.             When you go into labour you should stop thinking about what you have learnt and simply tune in to your instincts and do what your body tells you to do. Tune out from the world.

4.             Planning a home birth triples your chance of avoiding a caesarean, or assisted birth and also improves outcomes for mother and baby across the board, inc. length of labour and amount of pain. Everyone should at least consider this option.  After all, by planning for a home birth you are maximising your options – you can still go into hospital at any time.

5.             Cocoon yourself in labour to let the birth hormones flow freely.  You need to feel secure and in control enough to let go and let it happen. Fear makes your uterine muscles contract and labour more painful; fear releases adrenaline which slows down or stops the flow of the birth hormones. Let your birth partners be your advocates and protectors – let them deal with any hassles.  Be a queen.

6.             The uterus is a muscle and so you need to apply what you know about how muscles work best – be relaxed, breathe steadily, keep hydrated and fed.  Labour can be physically demanding.

7.             ‘Breathing through contractions’ is simply breathing out through your mouth in a rhythm.  By concentrating on your out breath, you keep your breathing steady (not holding your breath, nor breathing too fast), you get oxygen to your muscles and your baby, you will be more relaxed, and it gives you something to focus on, all of which reduces the pain.

8.             In a midwife group in London almost 80% of women (not having operative deliveries) had no form of artificial pain relief.  You can reduce pain of contractions by having good support, relaxing your body (go saggy with the pain), using distraction and positive thoughts, being upright and mobile, breathing steadily, looking after your muscle, using water, massage, and making the most of the interval between contractions (pacing yourself).  Women who think they will be able to cope report less pain than women who think labour will be unbearable.

9.             Pharmacological methods of pain relief use either muscle relaxants, mind-altering drugs, or interrupters of nerve messages.  By using the methods above to relax your muscles, change your perception of the pain, or to interrupt the pain messages, you can go longer without these, or work with them to make them move effective.

10.          It is not just important to have the baby’s head down, your birth will be smoother if the baby’s back is towards your front.  In late pregnancy there are things you can do to move the baby round; in labour, keep upright and leaning forward, moving (walking, marching, whatever your body tells you) and be prepared for a longer labour.

REMEMBER: It is your body, your baby, your birth. It is the law of this land that everything is your decision.  Health professionals can only recommend an action.  This applies to everything from where you give birth to having any treatment, including being induced.

Sunday, 23 October 2011

When is my due date?

Working out your baby’s due date is simple – and complex!  On average a pregnancy last 40 weeks from the first day of the last menstrual period (LMP) – or 38 weeks from conception.  Length of pregnancy is counted from the LMP, so four weeks after your LMP you would be counted as being four weeks pregnant even though you probably only conceived two weeks ago.  If you know when your LMP was, the easiest way to work out your due date is to go through the calendar counting forward in weeks till you get to forty weeks.  So if your LMP was on a Tuesday, then your due date will be on a Tuesday.  Counting 38 weeks from conception is more accurate, if you know when it was, especially for women who do not have regular 28 day cycles.

Health care professionals do not have time to count through the calendar so they use one of two ways to quickly calculate your due date.  The first is a wheel which has dates of the year on the outer wheel and the weeks of pregnancy on the inner wheel.  By matching 0 weeks on the inner wheel to the LMP date on the outer wheel, the corresponding due date at 40 weeks can be read off.  These wheels are also used to work out how many weeks pregnant you are at check ups.  These wheels are not very accurate and can be out by a day or two.

The other way is to take the LMP and add on nine months and seven days; for example, LMP 7 Jan gives a due date of 14 October.  Again this is an approximate measure and can be out by a day or two: in 2011 7 Jan is a Sat and 14 Oct is a Sun.

The first scan routinely offered in the UK is a dating scan, at about 12 weeks.  This is used to confirm a due date from LMP or to work one out if LMP is not known (as well as some checks for abnormalities).  It does this by measuring the length of the femur, I believe.  At this point in the pregnancy there is a good correlation between this measurement and predicted due date.  As the pregnancy progresses it is harder to assess gestation in this way as babies growth varies.  Later scan are less reliable in predicting size of baby too.  Research has shown that due dates from dating scans are more accurate than from LMP.  If, from this first scan, the due date calculated is more than a week different from that from LMP it is likely that the health professionals will change the EDD.   This can be confusing – for one of my friends it meant that, by the scan dates, she would have conceived when her and her partner were in different countries!

How can there be such discrepancies?  Of course she could not conceive without a partner and scans are only approximate.  It cannot be an exact science.  Women have varying lengths of menstrual cycles and do not all ovulate on day fourteen of their cycle.  Many women have unpredictable cycles.  Sometimes events in a person’s life can cause ovulation to happen earlier or later than usual.  You can decline the scan.  If you are sure of your dates then you do not need it to confirm this.  If you do not know your LMP and would like a scan to give you a due date then you can ask them not to check for abnomalities if you don't want to know (at this scan the nuchal fold is measured which is a marker for Down's Syndrome).  I had no routine scans with my last two - more about that another time - but with my last I had bleeding, at 12 weeks, that did not lead to miscarriage so I attended an Early Pregnancy Unit.  I was offered a scan to confirm life but I asked for no abnormality checks to be done, including nuchal fold.  This was written onto my notes and respected.  With all of my pregnancies I had decided not to take any abnormality screening, including triple test - but this is purely a personal choice that every couple must make for themselves.

However a due date is calculated – by calendar, by wheel, by rough approximation, or by scan – a due date is only an approximate date for baby’s arrival; in fact it is often written as EDD (estimated due date or estimated date of delivery).  Only 4% of babies arrive on their due date and ‘term’ is defined as any time between 37-42 weeks, so the baby could come any time 3 weeks before that date or up to 2 weeks after and still be considered normal – and some babies come earlier than 37 weeks and some later than 42!

So does it matter?

At the beginning of the pregnancy it is hard to imagine that one or two days difference in a due date matters.  We all like to have a date to consider.  We also have a tendency to wish the pregnancy by and want the baby to come as early as possible.  However, it is worth going with the latest due date from one of the methods – if the date given by midwife/gp/scan is later than from counting through the calendar, then keep quiet; but if it is earlier then insist on using your date.  By having a later due date you give yourself a bit more time and at 41 weeks every day will count.  You will feel pressure from yourself and others for the baby to come.  (Some women choose to tell family and friends that baby is due ‘sometime in June’ rather than give a specific day.)  Also in this country it is routine to offer induction to women to start labour off at 10 or 12 days after the due date.  Induction can result in a more painful labour and is associated with a higher use of epidural and assisted birth (forceps/ventouse).  If induction methods fail to get labour going or progressing then women will be given a caesarean.  So the later your due date, the less pressure and worry on you – for a day or two – which could be all that baby needs to come on its own.  (Of course you can decline induction – you can wait and be monitored.) 

And then you wait ...

Of course all of this has no bearing on when your baby will actually be born.  If anyone invented a way of giving women due dates that were accurate even to a day or two then they would be rich; instead we have to put up with not knowing and a 5 week window, which even then isn’t definitive.  Baby chooses the day – and from my experience babies want you to know from the start who’s in charge – them!

Pregnant? Now what?

So you’re pregnant?

Here are some things you should know straightaway...

How do you know you’re pregnant?
·         the most obvious is that you have missed your period
·         feel extremely tired
·         Breast changes: areola (dark area around your nipple) darkens, breasts swell, breasts are tender, glands (like spots) around the edge of your areola enlarge (they are called Montgomery tubercles)
·         Feel hormonal, like the start of your period; some women even feel period like aches.
·         Metallic taste in mouth
·         A positive pregnancy test: these are extremely accurate and if you have used one your gp/midwife will not do another.

What now?

Well – you could do nothing.  There is no need to see anyone or do anything.  If you don’t see anyone or have any checks your baby will grow and one day you will go into labour and your baby will be born – it’s nature, it’s what humans and cats and dogs and pigs and all other mammals have been doing for millenia.  However, antenatal screening has been shown to be beneficial – but it is up to you to choose which parts of it you want for you and your baby.  No test can guarantee a healthy baby, and you can’t jinx your pregnancy by not doing a test.  There are reasons for doing each test and check up, and you should weigh each up and decide.

Most people in the UK tootle off to see their GP or contact a midwife.  It has become more common in recent years to contact a midwife directly – you can get the details from your local surgery or contact the maternity unit at your local hospital.  There is a poster up in my local surgery and children’s centre with the number.  They will just want your name and contact details and the date of the first day of your last period – pregnancies are measured from this date which is often abbreviated as LMP (last menstrual period).
If you do go to a GP: they will want to know your LMP and will calculate your estimated due date (EDD, also known as estimated date of delivery).  (See next blog post for how this is done.)  They may check your blood pressure and listen to your heart.  Mostly they will just fill in a form to send off to the midwife.  They may ask you where you want to have the baby.  This is only so they know who to send the paperwork to.  You could ask what the options are in the area – choice of hospitals, any birth centres?  Most GPs have very little firsthand experience of birth so you may find the midwife is the best person to ask anyway.  It is perfectly reasonable to say ‘we haven’t decided yet’.  You can make a decision about place of birth, or change your mind, at anytime – even during labour!  Bear in mind, home birth is an option for first timers – in fact the first is often the best to have at home (see my blog post, first baby at home).  Sometimes GPs try to put women off homebirth or say it isn’t an option, but, again, they have little experience of birth, beyond a short time during their training.  It always strikes me as bizarre to be asked where you’re having the baby at a time when the main worry is whether you’ll miscarry, and you know so little about what birth is like and how your pregnancy is going to progress.

If you contact a midwife directly then you will not need this first appointment and will go straight to a booking visit.

Booking visit

Your midwife will contact you to arrange a booking visit.  These are usually done in a woman’s own home by a community midwife, at about 8-10 weeks, and last about an hour.  There is a lot of form filling and some discussions.  They will go through
  • Your contact details and your partners’
  • How and when to contact a midwife
  • Your medical history
  • Options for place of birth
  • Programme of antenatal checks, inc scans
  • Information about the benefits of breastfeeding especially straight after birth
  • Healthy pregnancy – diet, exercise, what to avoid, smoking, drinking, domestic violence

They will probably test your urine (they may give you a pot with a lid to keep so you can bring a sample of urine to each check up).  Urine is tested for levels of protein and sugar which can indicate potential problems.  They may take your blood pressure to give an early reading to compare later measurements to.  They may ask to weigh you, or ask you for your weight and your height, and thereby work out your bmi.  As with all tests you choose to accept or decline each.  Even though they are routine, there is no obligation to accept.

The midwife will be taking your details down twice – one in a set of notes you will be given to keep with you and bring to appointments and one kept by the midwife at the hospital.  You will be given a date for the first scan if you decide to have it, or the midwife will make an appointment for you and contact you later.  You will also be given an appointment for a blood test (or you’ll be asked to make one at your surgery). 

Further antenatal check ups will take place either at your gp surgery, children’s centre, hospital, birth centre or at home.  For more details of what is done at each check and how many to expect you can look at the national guidelines by NICE (National Institute of Health and Clinical Excellence – also see their guidelines on caesareans, anti d, care in labour and more).  Here is the link for the antenatal care guidelines.  They will send you a free copy of their patient copy or the professional’s version or you can view on line.

I hope this helps.  Early accessing of maternity care (contacting a midwife and starting antenatal checks before 12 weeks) is associated with improved outcomes.  If you are a first time parent then you are probably excited about the whole process – as I was.  By the time I was pregnant with number 3, 4 and then 5 I was much more laid back and didn’t contact the midwife till later.  With baby number 4 I was 17 weeks and with baby number 5 I was 16 weeks at my booking visit – but then I didn’t want any scans and knew that my previous pregnancies had been uneventful.

Early pregnancy units

Just a quick note before the end of this post.  Most hospitals have early pregnancy units.  If you think you are miscarrying you can just let nature happen.  However if you are bleeding and there is no sac, or if bleeding and pain continues, or you would like to know more you can ring up and make an appointment to go there.  If the pregnancy is at least 14 weeks they may be able to hear a heart beat.  They also offer scans. More pregnancies than you’d think have episodes of unexplained bleeding with no miscarriage.  (See previous post for more information about miscarriage and sources of support and information.)

Friday, 9 September 2011

So you’re thinking about trying for a baby?

My sister attended three weddings last year of her contemporaries, two of these couples have moved houses recently, and you know what they say – new house: new baby!  Anyway there are some things I think people should think about before getting pregnant and in early pregnancy, and there is some useful information out there that they might not be aware of.   As I probably will not know about their pregnancies until after this stage, I thought I would write some bits down.  This is not comprehensive, in fact I have tried to include information that I think is useful but is not usually available or discussed.

Pre pregnancy: Thinking about starting to try for a baby

1.            Be Healthy
It will be good for you and your baby to be as fit as you can before you get pregnant.  Being healthy is commonsense: eat well and exercise.  See any pregnancy magazine or website for foods to avoid.  Also rest.  Learn to listen to your body’s needs.

The healthier you are the healthier the baby will be and the easier your pregnancy and birth.  Whatever you put in your body your baby will have some too – if you have too much sugar, or fat, or alcohol, or nicotine, then so will your baby.  Your body will prioritise the baby over you to give it the nutrients it needs so if you don’t eat well you will find yourself depleted – pregnancy makes you tired enough without that.  You will need stamina – 

  • To carry the extra weight of baby, amniotic fluid and placenta
  •  To deal with the extra work your body does in growing and creating another human being from scratch
  • To cope with the extra strain on your body especially on your heart – by nine months, a pregnant woman’s heart – at rest – is working as hard as someone running a marathon, due to the extra blood the woman is pumping around her body and to the baby.  My then the woman’s blood vessels have doubled in diameter to cope with the extra amount of blood.
  •  To keep your strength up during labour – it is not called ‘labour’ for nothing – it is physically demanding and can last for many hours.

Being healthy before you conceive is important for both parents-to-be.  A woman’s eggs all develop when she is in the womb herself but sperm is made anew so it is especially important to be healthy before trying to conceive.  To-be-dads-to-be need to ditch the fags, reduce the alcohol, caffeine and fry ups. 

Smoking is the biggest factor in still birth, placenta problems, premature birth and small weight babies (this is NOT a good thing – small weight babies are more vulnerable, have greater problems when born, and may have greater problems being born as they have less resilience to the stress of birth.)  Smoking reduces fertility for men and women.

It seems obvious that pregnant women should stop smoking – though it can be hard, there are specialist smoking cessation midwives at every hospital – it is just as important for men to stop too – especially when trying to conceive.  Smoking affects the quantity, quality and mobility of sperm so reduces the chance of conception.  The placenta is formed from the division of the fertilised egg, so just as the baby is half dad, so is the placenta.  The quality of the placenta is vital to the baby’s growth in the womb, it ensures the baby gets the blood, nutrients and oxygen it needs.  In order to have sperm unaffected by smoking you need to quit before trying for a baby – some places say one month, some say three.  Ask your gp for more information.  Also, second hand smoke has been linked to the same problems for the baby as the mother smoking.

2.            Relax and enjoy the practice!
On average it takes between six and thirty months to conceive.  Stress can reduce your chance of conceiving.  The more sex you have and the more you enjoy it the better the chance of getting pregnant – better pH of fluids, more blood to womb.  Learn about your body: notice changes in your vaginal mucus when you are ovulating. 

If you have trouble conceiving here are some useful websites:

3.            Girl or boy?

There are several theories about how to increase your chance of conceiving a boy or a girl.  One is based on the idea that ‘male’ sperm travels faster but ‘female’ sperm keeps going longer; so if you have sex shortly after the egg is released the sperm has further to travel so baby will more likely be a girl, but if you have sex in the days after ovulation then there is less far to travel and the faster ‘male’ sperm will get there first.  How do you know when you ovulate?  On average women ovulate fourteen days into the menstrual cycle, but everyone is different.  Women often notice a change in discharge (like egg white).  Get to know your cycle.

4.            Miscarriage
Miscarriage is more common than most people realise (one in three pregnancies).  Miscarriage is most common before thirteen weeks.  Most of these are because although the placenta and the sac started to grow, the baby didn’t.  Most miscarriages are completely spontaneous and there is no need to contact a doctor or midwife unless concerned.  It is very common to grieve for the loss of your baby and the loss of the future you planned.  

Bleeding does not necessarily mean miscarriage.  Many women experience unexplained bleeding in early pregnancy.  Most hospitals have Early Pregnancy Units which you can just ring up and usually attend that day.  They may offer you a scan – either through the abdomen or the vagina.  It is hard to hear the baby’s heart beat before fourteen weeks.  You can decline any part of the care.  Just by going along does not mean you consent to everything.  You can wait it out – just like our mothers and grandmothers had to do.