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    First Baby Policy For

    Ronnie Falcao, LM MS CPM


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Dear First-Time Mother,

Becoming a mother for the first time is a wonderfully exciting time in your life, and giving birth for the first time is an amazing life experience.
Sometimes, it is also quite challenging to give birth to a first baby.

When women start care with me as their midwife, I really want them to have the homebirth they want, as long as it's safe.
In looking back on the births that have required a transfer of care instead of having the homebirth we all wanted,
I have identified key factors in having a safe, happy, first-baby homebirth. *

Thus I have instituted a first-baby policy for the time being so that both you and I can be confident that you are very likely to have a homebirth.

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I strongly encourage first-time mothers to do all the following:

Get your omega-3 fatty acids (DHA, etc.) from your foods and not from supplements.
Omega-3 supplementation may make your baby's brain bigger, but this also makes the head bigger!
You can take choline, instead, during pregnancy, since this nurtures the nervous system and brain.
And then after the baby is born and the head has passed through your pelvis, THEN you can take omega-3's,
and they still benefit your baby's brainsize and IQ for the first three months of breastfeeding.
As much as you want your baby to have all the advantages you can give, you have to balance
the advantages of an unmedicated birth at home with the medications or cesarean that
might become necessary if the baby's head is too big to pass through your pelvis normally.
[NOTE - If you do take omega-3 fatty acids during pregnancy, it is important to stop taking them
at least a couple of weeks before your due date as they can delay the onset of labor.
Omega-3 fatty acids have anti-inflammatory properties, and the ripening of the cervix
in a term pregnancy is an inflammatory process and could be hampered by omega-3s.]
If you feel very strongly about taking omega-3 supplements and still want to have a homebirth,
it is possible to take herbal supplements to encourage the baby to come in a timely fashion,
before the head grows too big or hardens too much to compress through the pelvis.

- Take Bradley childbirth preparation classes.  Investigate these early to get into a workable class cycle.
Bradley classes do a great job of teaching about the progress of labor and supporting natural childbirth.
I find that Bradley couples are much more likely to have a normal homebirth.
If you want to take Hypnobirthing or Birthing from Within classes in addition, I think that's a great idea.

- Hire a professional doula who has been the primary doula for a high percentage of unmedicated first-baby births.  Make sure that she will be with you
anytime you're in pain, even if it's early labor or if you can't sleep for more than a few hours because of contractions.
It's best to have made a decision about your doula by about six months.
A doula who focuses on relaxation rather than fighting or "working" your labor seems to result in easier births.
The following doulas have helped my clients having successful first-baby homebirths:
Hope Willems - a number of happy births, including first baby and VBAC
Ashley Franke
Tricia Mittra
Deidre Lorenzo
Jennifer Wolfe
(This item is less important if your partner is very enthusiastic about attending Bradley classes,
coming to prenatal appointments and especially about being your sole labor support.
Your partner must also be a calm, nurturing person who gives you absolute confidence about
their ability to care for you during this most vulnerable time.  They must be able to stay awake
through the night, possibly multiple nights, and to put their own needs aside in order to tend to yours.
I can usually get a sense of whether your husband is likely to be a good first-time doula for you
after a few appointments.  Please note that if your husband is anxious about becoming a father,
or anxious about the birth, or himself had a difficult birth experience, he might not be capable of
being a good doula for you.  This in no way indicates that he doesn't love you beyond all knowing
or that he won't be a good father; it just means that he's not a professional doula, has probably
never attended a birth before, and may need some support himself.  If you know for a fact
that he tends to doze off after midnight and simply cannot keep himself awake, then it's going
to be even more difficult for him when the air is infused with oxytocin and endorphins, which
seem to act as sedatives for men.  A good doula will actually liberate your partner to be more
involved in the birth because there is so much less possibility of disappointing you.  And, yes, I have
certainly seen births where we ended up at the hospital because there was no professional
doula there for the mom.  I can't be both your doula and your midwife.)

- Plan on setting up an Aquadoula birthing tub for pain management.  I loan or rent these out for all first babies.

- Plan on privacy during labor and birth.  The non-professionals you invite to your birth should be either someone
who has had a homebirth or someone who was in the room when the baby was conceived.
Even if you have family visiting around the time of the birth, plan for them to stay somewhere else for the labor and birth.
First-time mothers labor best with only professional midwives and doulas at the birth to assist you and your partner.
This means no additional family or friends present until after the baby is born
and both the mother and baby are stable after the birth, usually at least an hour afterwards.
This is the most important factor in having a homebirth.*

- Spend at least ten minutes each day in deep relaxation.  This can be as simple as taking a bath
or relaxing deeply with calming music while you focus on connecting with your baby.
Or you can breathe deeply, meditate, assume a restorative birth yoga posture or practice guided imagery from among the CDs I will provide.

- Take gentle preparatory herbs in the last month of pregnancy. These will help to efface the cervix so that your early labor doesn't go on
for multiple nights.  You may choose from among the herbs I will provide.

- Take stronger herbs to bring the baby promptly if my assessments and followup ultrasound show the baby to be big for the mom
or you're more than ten days past your due date or there are other complications necessitating a timely birth.

- Follow my recommendations for addressing physical and emotional situations which I think might interfere with a normal birth.

- Confront any "birth tigers" by taking a "Birthing from Within Class" or doing this work on your own by 36 weeks.

Rest in bed after the birth until the milk has been in for at least two days and you're past the engorgement phase.
Stay home until baby's regained the birthweight and jaundice is fading - about ten days.
Keep baby home until two weeks after the birth, when the danger of birth-related infections has passed.
 

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Following these recommendations will make it much more likely that you will have the homebirth you want
and that we both look back on our time together with great pleasure.

If your choices are very different from these general recommendations in a way that is likely to affect your birth,
I may decide I cannot continue to be your midwife,
You are still financially liable for the services you have already received, including the initial retainer.
Or, if I think you're likely to have your baby at home but will simply have a prolonged labor,
I may require you to pre-pay for the extra time I expect to be spending with you beyond the time specified in the financial agreement.
Direct payment for my time bills at $220/hour when pre-paid; some insurance companies
will reimburse you for this time; some will not.
You may use your credit card through PayPal to make this payment.

I appreciate feedback about your reaction to this policy, as it's new.

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Frequently Asked Questions

Q: My mother / sister / aunt / cousin is a nurse and has offered to come help at the birth.
I'd like them to be there to help.  How could that cause a problem?

A: Family members will naturally feel concerned while you're in labor.  After all, even if
you're feeling completely comfortable, they're likely to be worried that you might be in pain
at some time in the future or that there might be a complication at the birth.  And even
the calmest person is likely to have some concern about homebirth unless they're thoroughly
familiar with the homebirth safety statistics.
Because they are not professional birth attendants, they will probably not be able to hide
their concern.  And, really, you might actually want them to be concerned, as their way of
showing love and support for you.  Unfortunately, their concern is likely to have a touch of
anxiety to it, and if there is any adrenaline in the air, it makes your labor painful and longer
and can cause a variety of complications at the labor and birth.

Even professional birth attendants know that their presence at the birth of one of their own family members
could cause problems. Even assuming that they have mastered the birth attendant's art of being fully present
to a birthing woman without showing unnecessary concern or pity, it is very different when it's your own sister or
daughter, and they are likely to become anxious.

I think the biggest problem with having family present at your birth is that they never think that ANY kind of care
is good enough for their precious niece/daughter/sister.  So this immediately puts them at odds with the professional
                         caregivers, which the birthing woman is going to notice, even if only on a subliminal level.
 

Q: One of my friends is a professional doula, and she's offered to attend my birth for free.  Will that work?

A: Probably not. This has all the problems of having family members there, with the additional problem
that if the doula is offering her services as a personal favor, then she's thinking of you as someone
in the personal side of her life, rather than the professional side of her life.  In general, the personal side
of a birth professional's life suffers when she has any professional obligations, so you might end up
playing second fiddle to her other clients, her family, and all the other parts of her life that she would
normally give higher priority than your friendship.  If you're not paying for her professional services,
you can't expect to receive professional service.
 

Q: My mother really wants to be at the birth, and I don't feel that I can say "No" to her.

A: This is the worst possible situation, and I have seen a couple of these situations that have
resulted in a pathological retraction ring, requiring a c-section.  If your mother is domineering
with you, then how could you possibly feel comfortable releasing your baby into a situation
where your mother might be domineering with your baby?  Your baby deserves a confident
mother who can make decisions that are best for the baby, even if your mother disapproves.
A therapist can help you work through these issues and develop healthy boundaries
with your mother, including telling her you want privacy at your birth.
(Julie Motz [415 256-2528 or jamtoday@juliemotz.com], in Tiburon, offers
HOW TO TALK TO YOUR PARENTS, A WORKSHOP FOR ADULT CHILDREN.)
 

Q: My husband really wants to be my primary labor support, but he finds our birth classes boring.
Can we just watch a childbirth education video instead?

A: You deserve to have labor support that makes you feel completely cared for.
If your husband isn't paying attention at birth classes and making sure that you schedule time
to practice coping techniques together, then he may not learn the skills necessary to provide
good labor support.  And if he finds the birth classes boring, I worry about his ability to remain
fully present to you during a labor which might span two nights.
It sounds as if you will be best supported by a professional doula in addition to your husband.
 

Q: My husband doesn't really want to be my primary labor support, but I really want him to be.
I feel like it will bond us more as parents, and I'm afraid a doula will interfere with that.

A: Part of the beauty of having good professional labor support is that when the
father is relieved of the pressure to be a great doula, he can often do a better job of being
a great husband and father.  A good doula will spend time talking with you about how to support
connection with your partner while she tends to your physical needs.
 

Q: I see all these great videos that show lots of family at the birth.  Why don't you like family at the birth?

A: I have almost never seen a situation where having a family member there has been helpful at a first-baby birth.
All the family dynamics change after the first baby, and then it is often helpful to have a mother or
sister present for second baby births.  I'm not a sociologist, so I can't explain all of this, but I know that my statistics
have consistently implicated family presence as a significant factor in problems at first-baby births.
My policy has evolved out of 12 years of watching births go really wrong when women rely on
family members to provide a type of care they're not trained in and which they cannot
provide professionally because they're your family!

I have a limited number of spots on my birth calendar, and it makes sense for me to take clients
who are likely to have a homebirth.
 

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* Statistics: Over the course of the last four years, my overall transport rate has been 10%.  For first babies, the transport rate is 25%, and for women having second or subsequent babies, the transport rate is 4%.  In the last four years, all of the first-baby transports have been among women who had family or friends providing labor support instead of their partner or a professional doula; in fact, for first-baby clients, those who had family present had a 100% transport rate.  Of the first-baby clients who did not have family present, none of them transported to the hospital; half of them also had doulas.  Of the last four first-time mothers who had their own mothers present at the birth, all ended up giving birth in the hospital: two had a c-section, one had a vacuum extraction, and another had a very difficult pushing stage.

P.S. If you don't want to follow some of the above guidelines, I may still agree to be your midwife if you agree to pay my complete direct-payment fee up front.  (Note that my direct-payment fee is significantly higher than the base fee for "accepted" insurance plans.)  You must also agree that we will transfer care to the hospital after I have been with you for twelve hours during labor or at anytime that I judge that it is very unlikely you will give birth within twelve hours of my arrival, and that I will then go home after you are settled in with new care providers in the hospital.  Or I may recommend to transfer to the hospital early so that I may go home to sleep and then come back to the hospital later if complications arise or to assist with pushing/birth/breastfeeding.  I will then resume the normal cycle of postpartum care the day after you go home from the hospital, with some of the home postpartum visits forfeited.  (Optionally, you may request that I arrange for a backup midwife who can come to care for you during a long labor so I can go home and rest so I can come back when you start pushing, by which time I should be rested enough that I can be alert enough to provide safe midwifery care for the birth and another six hours afterwards.  The fee for a backup midwife is a base fee of $500 plus $220/hour.)

There are other local midwives who do not have these recommendations, and I encourage you to contact them if you feel a strong opposition to my recommendations for first-baby preparation.
 

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