I'm looking forward to the weekend. I've been so tired lately so I can envision lots of naps. I still want to walk a lot so I will be doing that as well to try to get things moving. I'll have an appointment on Monday and the last time we talked to the doctor, he said he'd let me go a week after my due date before wanted to do some tests to make sure everything looks and responds well. I'm really hoping this baby comes because I don't want to be induced at all. The less intervention, the better my chances are of doing this naturally.

My husband is getting really excited and he's having dreams of the baby arriving. I have had a few dreams but my last one was about me waiting and waiting and waiting. A couple of my friends have also had dreams about me having the baby but I keep waking up with no activity! What is it going to take?!

After attending both home and hospital births as a doula, I can honestly say that most women do not know how easily preset hospital policies can negate a birth plan or at least make it more difficult to enact without pushing for patient rights.

For instance, hospitals that restrict food and drink intake during labor unwittingly decrease a laboring woman's energy level, making it difficult for her to manage increasingly strong contractions, causing her body to tense up and stop dilating. If a woman does not dilate for a few hours, it's off to the OR she goes!

Another example is how easily a woman can be labeled high-risk, when in fact her situation may simply be a variation of the normal. If a woman is labeled high-risk without good reason, she is essentially prepped for the OR without being told about it. Thus a woman can be trying very hard to have a good vaginal birth experience (despite IV, fetal monitor, various drugs, food and drink restriction, and being stuck in bed) only to end up with a cesarean because those interventions make it more likely and because the hospital staff know that with a cesarean rate of 30% or more in thier hospital, her chances are not very good that her birth plan will come into being.

Although many women do not mind having cesareans, there are many more who feel regret, disappointment, and even depression over not being able to have an empowering birth experience. All feelings are legitimate, but because so many women react negatively to having a cesarean, they need to know how legal, monitary, and fear issues affect their hospital births more than any health factor.

If you really want to have a vaginal birth in the hospital, this is what you need to do:

1. Learn when interventions are actually called for - any restriction, intervention, or tool used in your care can begin the "cascade of interventions".

2. Learn your patient rights. There are federal, state, and hospital patient right bills, all essentially saying that you have the right to have your care provider give you information on both sides of the proposed intervention, and the right to accept or refuse anything your care provider offers.

3. Make a list of oth reasons your ideal birth is so important to you and remember them.

4. Make a list of potential complications and how you would respond to them. How far are you willing to go to protect your rights, and at what point will you accept your care provider's recommendations for treatment?

5. Hire a doula. Doulas have knowledge of patient rights, birth plan options, research, and hospital policies. They also have a history of reducing rates of all major interventions, and increasing patient satisfaction.

6. Choose your care provider carefully, interview them thoroughly before they begin giving you care.

7. Learn as much as you can about the process of birth so that you will be able to ask questions and have a better understanding of what your body needs in labor.

Please note that many care providers do their best to work outside of the norm and to avoid potentially harmful hospital policies. Unfortunately the odds are against them and regardless of how good your care provider is, you may still end up with an undesired birth experience. Why am I telling you this? Because if you want to get the experience you desire, you are going to have to know how the system works, and how to get what you want despite that system.

It recommends that midwives and doctors provide women with evidence-based information about a range of key issues such as why induction is being offered, the risks and benefits of induction and different pain relief options, so they can make decisions that are right for them and their baby. Key recommendations from the guideline include:

o Women should be informed that most women will go into labour spontaneously by 42 weeks.

o At the 38 week antenatal visit, all women should be offered information about the risks associated with pregnancies that last longer than 42 weeks, and their options.

o Healthcare professionals should explain the following points to women being offered induction:

- The reasons for induction being offered

- When, where and how induction should be carried out

- The arrangements for support and pain relief

- The alternative options if the woman chooses not to have induction of labour

- The risks and benefits of induction of labour in specific circumstances and the proposed induction methods

- That induction may not be successful and what the woman’s options will be.

o Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy

o If a woman has preterm rupture of the membranes after 34 weeks, the maternity team should discuss the following factors with her before a decision is made about whether to induce labour, using vaginal prostaglandin E2 (PGE2)

- Risks to the woman (e.g. sepsis, possible need for caesarean section)

- Risks to the baby (e.g. problems relating to pre-term birth)

- Local availability of neonatal intensive care facilities.

o If induction fails, the subsequent management options include:

- A further attempt to induce labour (timing should depend on the clinical situation and the woman’s wishes)

- Caesarean section.

Breakfast - 2 eggs cooked in butter (1.2 carbs), 1/2 cup green beans (2 carbs), 1/4 cup zuchini (0.5 carbs), 1/4 cup mushrooms (0.6 carbs), 2 oz pepper jack cheese (2 carbs)

Total -6.3 carbs

Lunch - 8 oz hamburger patty, 1 cup romaine lettuce (1 carb), 1/4 cup cauliflower (0.5 carbs), 1/8th cup sweet pepper (0.6 carbs), 0.25 oz Parmesan cheese (0.3 carbs), olive oil and vinegar dressing

Total -2.4 carbs

Dinner - 10 oz salmon, 2 tbsp mayo (1.5 carbs), 1 tbsp lemon juice (1 carb), 1/2 cup zuchini (1 carb), 1/4 cup sweet pepper (0.6 carbs), 1/4 cup mushrooms (0.6 carbs), 1/2 cup broccoli (2 carbs)

Total - 6.7 carbs

Daily Total - 15.4 carbs

$latex \textrm{Let } P(n) \textrm{ be the statement that} M^n = \begin{pmatrix} 1-3n&9n\\-n&1+3n \end{pmatrix} \\ \textrm{where } M = \begin{pmatrix}-2&9\\-1&4\end{pmatrix}$

Prove $latex P(k)$ is true $latex \forall k \in \mathbb{N}$

$latex \textrm{Let } k = 1$
$latex \Rightarrow M^1 = \begin{pmatrix}1 - 3&9\times 1\\-1&1+3\end{pmatrix} = \begin{pmatrix}-2&9\\-1&4\end{pmatrix}\\ \Rightarrow P(1) \textrm{ is clearly true.}$

$latex \textrm{Now suppose that } P(k) \textrm{ is true for some } k \in \mathbb{N}$
$latex \Rightarrow M^k = \begin{pmatrix} 1-3k&9k\\-k&1+3k \end{pmatrix}$
$latex \textrm{Then} $
$latex M^{k+1} = MM^k = \begin{pmatrix}-2&9\\-1&4\end{pmatrix}\begin{pmatrix} 1-3k&9k\\-k&1+3k \end{pmatrix}$
$latex = \begin{pmatrix}-2 + 6k - 9k&-18k+9+27k\\-1+3k-4k&-9k+4+12k\end{pmatrix}\\ \\ =\begin{pmatrix}-2-3k&9k+9\\-1-k&4+3k\end{pmatrix} \\ \\ = \begin{pmatrix}1-3(k+1)&9(k+1)\\-(k+1)&1+3(k+1)\end{pmatrix} \Rightarrow P(k+1) \textrm{ is true }$

Since $latex P(1)$ is true and $latex P(k) \Rightarrow P(k+1)$ the result follows by mathematical induction

Breakfast - 2 eggs (1.2 carbs), 1 oz feta cheese (1 carb), 1 oz garlic jack cheese (1 carb), 1/4 cup zuchini (1 carb), 1/4 cup sweet pepper (1.2 carbs), 4 strips bacon

Total - 5.4 carbs

Lunch - 3 oz can tuna, 1 cup mixed salad (1 carb), 1/4 cup cucumber (0.5 carbs), olive oil and vinegar dressing

Total - 1.5 carbs

Dinner - 2 thin steaks (2 carbs from marinade), 1/2 cup green beans (3 carbs), 3/4 cup cauliflower fried in butter (2 carbs

Total - 7 carbs

Daily Total - 13.9 carbs

Breakfast - 2 eggs cooked in butter (1.2 carbs), 1/2 cup green beans (3 carbs), 1/4 cup red pepper (1.2 carbs)

Total - 5.4 carbs

Snack - 1 oz colby cheese (1 carb)

Total - 1 carb

Lunch - 1 cup mixed salad (1 carb), 1/4 cup cucumber (0.5 carbs), 1/8 cup mushrooms (0.3 carbs), sprinkle of bacon, olive oil and vinegar dressing

Total -1.8 carbs

Dinner - 8 oz turkey breast, 3 brussels sprouts (2.5 carbs), 1 cup salad greens (1 carb), 1/4 cup sweet pepper (1.2 carbs), 1/8th cup cucumber (0.3 carbs), sprinkle of bacon, olive oil dressing

Total - 5 carbs

Daily total - 13.1 carbs

Breakfast - 2 eggs cooked in butter (1.6 carbs),1/4 cup red pepper (1.2 carbs), 1/2 cup green beans (3 carbs), 1/8th cup green pepper (1 carb)

Total - 6.8 carbs

Lunch - 4 large pepperoni slices, 1/2 oz feta cheese (0.5 carbs), 1 cup mixed salad greens (1 carb), 1/4 cup cauliflower (0.5 carbs), olive oil and vinegar dressing

Total - 2 carbs

Snack - 1 oz colby cheese (1 carb)

Total - 1 carb

Dinner - 8 oz chicken, 1/4 cup mashed caulflower (3 carbs), 1/2 cup brocolli (2 carbs)

Total - 5 carbs

Daily Total - 14.8 carbs

I am now really trying to limit my intake of cream, cheese and sweeteners. I am also upping my veggies a little so that I can try and get a little more veggie carbs during the day. Its all a big experiment people. I gotta know if I am semi-stalled because I am not getting enough of my carbs from veggies. I have lost a couple more inches on my waist, chest and arms though so I know that technically I am not stalled at all. I sure do get frustrated with the scale and want it to move faster though!

Breakfast - 1/2 cup zuchini (1 carb), 1/4 cup pepper (1.2 carbs), 2 eggs cooked in butter (1.2 carbs)

Total - 3.4 carbs

Lunch - 4 large pepperoni slices, 1 cup mixed greens (1 carb), 0.25 oz parmesan cheese (0.3 carbs), 1/4 cup cauliflower (0.5 carbs), olive oil and vinegar dressing

Total - 1.8 carbs

Snack - 1/2 cup jicama (2.5 carbs)

Total - 2.5 carbs

Dinner - 8 0z hamburger, 1 oz swiss cheese (1 carb), 1 cup green salad (1 carb), 1/2 cup green beans (3 carbs)

Total - 5 carbs

Daily Total - 12.7 carbs

My name is Guy.  I like to make websites.

What I don't like, however, is making websites the way other people want me to make them. Why don't I like that? Because other people are weird and sometimes sticky. Maybe it's also because I like to be my own boss, and because I have a deep, long-established trust in my own judgement in the area of web development. It's mostly the sticky part, though.

I've been making other peoples' websites the way other peoples want for not actually very long, but I already know, deep down in my face somewhere, that it can't go on this way forever. I love what I do, but I have to do it for myself for it to really feel right. That's probably a sentiment shared by many other faces who have a job working for someone else; especially a creative job.

So I want to make some websites for myself. And I want to make money with them. Because I need to eat. But that's not the only reason.

The Purpose

I really like making really cool stuff. Business websites and static information portals are great, and very important parts of the internet, but I get very bored very quickly if I'm the one who has to make them. I want to make stuff that doesn't just come straight from the desk of the editor. I want to make stuff that enables people to connect and use the internet in ways that foster a free exchange of ideas and content. My ultimate goal is to make an impact on the relationship between science and the average person. We have a worldwide network of computers talking freely to each other, and we can barely hear any real information over the clamor of millions of random videos of cats.

The Problem

Another thing I have in common with most of the faces of the world is a natural talent for beautiful, masterful, exquisitely crafted procrastination.  This problem, of course, comes from an even deeper need to be completely devoid of motivation for the majority of my waking hours. In the past, my projects have only existed in my head. I want to do so many things, but I never even get started. I just don't know where to go, what to do first, how to prevent my ass from being thoroughly sued off, etc.

The Solution?

Enter this blog. I hope to fix this part of the problem by laying out all my dreams and desires in text form for the whole internet (or at least a very very very very very very small part of it) to read. Hopefully I'll actually make a little progress; and maybe being able to see, in blog form, where I've been and how far I've come will give me an extra antiprocrastinatorial boost to get me to the next step.

That's also where you come in, Internet. I'll inevitably be asking a whole lot of questions over the course of writing this blog, and I'm counting on you to at least make fun of them, if not answer them.

The Secret

I won't be sharing a lot of details, personal or otherwise, on this blog. It's not that I don't want anyone to find out who I really am, but I'd rather not have this come off as a marketing device like so many other "lol I'm making a thing, come read about it" blogs definitely are. This is purely a tool to get myself started and to keep myself going through the process. Maybe it'll also help someone else who wants to join the festering zombie mob of web start-ups. That's assuming I succeed, of course.

My name isn't really Guy, and I probably won't reveal what my project actually is. That will most likely be pretty hard to keep up while still providing enough information to be worth reading, but I know I'll think of some way to drive all of you with me to my destination without passing any recognizable landmarks.

So hello, and thanks in advance for reading, Internet.

- "Guy"

Breakfast - 2 scrambled eggs cooked in butter (1.2 carbs), 1/2 cup zuchini (1.1 carbs), 1/4 cup yellow pepper (1.2 carbs)

Total - 3.5 carbs

Lunch - 1 cup mixed greens (1 carb), 3 oz can tuna, 1/2 cup jicama (2.5 carbs), 1/4 cup cucumber (0.5 carbs), olive oil and vinegar dressing

Total - 4 carbs

Dinner - 8 oz salmon, 2 tbsp mayo (1.5 carbs), 1.5 cups salad greens (1.5 carbs), 1/4 cup cauliflower (1 carb), 1/4 cup cucumber (0.5 carbs), olive oil and vinegar dressing

Total - 4.5

Dessert - 2 oz cream cheese (4 carbs), 1 tbsp butter, 2 tbsp davinci syrup

Total - 4 carbs

Daily Total - 16 carbs

Organizational Excellence: Retention management
Talent Management & Development: Internal job rotations, performance management
Work Environment & engagement: Employee interactive forums, one on one, fun at work
HR Functional Excellence: Internal/ external surveys, one on sessions, review meets, appraisals, induction
Note:  Looking for candidate who had completed their graduation.

Desired Profile:

- The candidate should have good communications skills
- Should be willing to work in any of the following locations - Mum/Pun/Del/Ban

Contact Person: Sudip Mukherjee.

Interview Date: 19th July 08.

Interview Timing: Between 10.30 AM to 12.00 PM.

Please Apply / Find more Information @ Freshers Home

This notion really ticks a lot of people off. Anthony Colpo, who wrote a terrific book The Great Cholesterol Con, says this about it:

There's just one wee problem with the metabolic advantage theory of weight loss: It is complete bullshit.

Ok - so Anthony is a bit strident. Actually, I find a number of people who discuss nutrition a bit 'over the top' in delivering their message. These people are so sure of themselves, that there is no room for disagreement, and notions that disagree with their beliefs on nutrition need to be crushed.

Me - I'm OK with not being certain, as I have mentioned before. I keep myself humble by referring to the list of cognitive biases, and reminding myself: there's a good chance I'm wrong.

I don't claim to have the answers to this, and I'm not a scientist by any means. I do have questions, however, based on my so-called research.

For example, I've read about coconut oil. Coconut oil is comprised of what's called medium chain tryglycerides - MCT for those of you that love acronyms.

Here's an interesting fact from Wikipedia ('If it says so in Wikipedia, it has to be true'):

MCTs passively diffuse from the GI tract to the portal system (longer fatty acids are absorbed into the lymphatic system) without requirement for modification like long chain fatty acids or very long chain fatty acids do. In addition MCTs do not require bile salts for digestion. Patients who have malnutrition or malabsorption syndromes are treated with MCTs because they do not require energy for absorption, utilization, or storage.

So...if I read this correctly, it takes less energy to absorb MCTs than other fats. Now, regarding energy, there's no free lunch in this universe. If it takes less energy to absorb MCTs than other fats, doesn't that give them a 'metabolic advantage'? mean that not all calories are alike?

Next up is sugar. From the always fascinating Weston A. Price Foundation:

Sucrose is a disaccharide composed of 50 percent glucose and 50 percent fructose.

...Glucose is metabolized in every cell in the body but all fructose must be metabolized in the liver.

So again, we have sugar, with is half glucose and have fructose. One half is directly absorbed by the body, the other half has to go to the liver to be transformed into something we can absorb. Surely it takes more energy to take a trip to the liver and have it do work to convert the fructose, so wouldn't it stand to reason that a calorie of fructose requires more energy to absorb than glucose?

Here's what I think the problem is: the truth is - we have no way to measure exactly how food energy is absorbed and what energy is absorbed and what is consumed to absorb it. But we humans love to measure stuff, so we came up with a model.

We took the energy unit, a calorie (a Calorie with a capital 'C', or kcal to be anal about it) and used this as a yardstick.

Do you know what a Calorie really is? Again, from Wikipedia:

One food Calorie (1 kcal or 1,000 calories) is the amount of digestively available food energy (heat) that will raise the temperature of one kilogram of water one degree Celsius.

So a calorie is a unit of energy to heat a kilogram of water 1 degree Celsius. This has nothing to do with human metabolism - we aren't as simple as a bucket of water, are we?

Well, the folks that are aching to measure this stuff aren't that stupid, so they account for that by that phrase 'digestively available'.  What the heck does that mean?

The particular food being measured must be burned in a calorimeter, so that the heat released from the food can be accurately measured. This amount is used to ascertain the G.E.V. of the specified food. This number is then multiplied by, usually, 85%; which represents the loss happening during human digestion.

So - if we want to know how many calories are in that Twinkie, we can put it in a calorimeter, burn it to ashes, and measure how much heat was given off. Then we multiply by 85% to account for our body's energy overhead to turn the Twinkie into something we can absorb.

Why 85%? I think the answer lies somewhere in the G.E.V. - an undefined acronym in the article. After some head-scratching on this one, I was led to Wilbur Olin Atwater - a fellow born in 1844 who came up with a system that tried to measure the energy in different foods. It is a  noble attempt to understand a complex process, but as the Wikipedia entry itself states:

Its use has frequently been the cause of dispute, but no real alternatives have been proposed.

So...what I see is a very complex system of adjustments and coefficients that try to measure the unmeasurable act of metabolism within a human individual - a best guess at how many calories are really in the food as opposed to how much we measure in the calorimeter.

The problem with guesses, especially when you do a lot of them, is that some are closer than others. So calculating calories for a given food is pretty much a crap-shoot - a statistically justified and rigorously measured crap-shoot, but a crap-shoot nonetheless.

Just because there's a pile of research data and statistical analysis doesn't mean anyone really knows with a degree of certainty  how one food might compare to another in terms of a net energy gain when you eat it.

But...it gets worse.

Let's say you review what I've written above and conclude I am totally clueless and that calories are indeed a valid measure of the foods you eat. You believe that counting calories works, and you keep your little book that says this food is 47 calories per serving and that one is 98. You tally this on a little pad you tote around all day and at the end of the day you sum your numbers and come up with 1478 - just shy of your goal of 1500 calories per day.

What you have here is what I call 'the illusion of exactitude'.

We don't really know how many absorbable calories are in a given food item, though there's been some painstaking calculations done to make it appear we do.

Then the manufacturer of our Twinkie doesn't really put the thing in a bomb calorimeter - they calculate the calories from the list of ingredients and the previously derived values for each of them.

They tally that up, then create the nutrient data label that decorates our Twinkie box.

These labels themselves are more illusion. As stated here:

Because we know how many calories are in a gram of protein (4), carbohydrate (4), or fat (9), you would think you could calculate the number of calories just by knowing the amounts of these nutrients.  But if you do the math, sometimes the result doesn't match the number of calories shown on the label.

And here, in deciphering how labels can game the system - referring to a food label for 'fat free' margarine that claims to have 5 calories per serving but really has 61 (scroll down past the entry on gum):

...but on a technicality they remain hidden from the consumer. A high-fat food is passed off as a low-calorie food. Isn't this malevolently crafty? It is a very cruel joke played on people who count calories trying to lose weight.

There are other people questioning the 'calorie is a calorie' mantra - and my own personal experience tells me that food intake does not necessarily have a direct correlation to energy absorbed - and turned to fat on my ass. So is there a metabolic advantage in eating a certain way? My own experience on myself says yes.

Based on what I've seen above, calories as we normally think about them are total bunk.

Calorie-counters: you have my sympathy.

Recently I came across this interesting article/practice at Patni Computers:

On his first day to work at Patni Computers, 23 year old Arshad Shaikh had sweaty palms and an itchy neck. The mild apprehension of how his first day at work would be was worrying him. But, surprise surprise! A badge with a smiley face and ‘Just Joined’ stamped on it was given to him. “I can’t tell you how good I felt that day. There were unknown faces coming up to me and offering help. This practice we have, called ‘Just Joined’ is a great HR practice,” gushes Shaikh, senior analyst, Patni. “Moreover, all the process related information was shared with me right on day one to make things easier. I felt settled from the first day itself,” he adds.

There are numerous reports that would tell us how 70% of employees leave within the first 1 year of joining. People who stay on for more than a year have a high likelihood of completing a good run with the Company. Knowing this fact the entire period of pre-joining formalities, induction program and post joining first 1 year of engaging employee becomes extremely important. Having said that most of the companies have a ‘standard’ induction manual that’s delivered like work as usual in first week of joining etc and else everything just operates as usual for all employees. There isn’t much to differentiate between programs or ways of engaging employees as far as new employees are concerned.

While I have come across some very interesting practices in various organizations, I found this something very interesting….small initiative but interesting. Might be bordering more on a IT/ITES (BPO) environment though.

Have you come across any interesting practices in Service Industry in particular….???

~~Rohit~~

One day while walking down the street a highly successful Human
Resources Manager was tragically hit by a bus and she died. Her soul
arrived up in heaven where she was met at the Pearly Gates by St.
Peter himself.

"Welcome to Heaven," said St. Peter. "Before you get settled in
though, it seems we have a problem. You see, strangely enough, we've
never once had a Human Resources Manager make it this far and we're
not really sure what to do with you."

"No problem, just let me in," said the woman.

"Well, I'd like to, but I have higher orders. What we're going to do
is let you have a day in Hell and a day in Heaven and then you can
choose whichever one you want to spend an eternity in."

"Actually, I think I've made up my mind, I prefer to stay in
Heaven",said the woman

"Sorry, we have rules..."

And with that St. Peter put the executive in an elevator and it went
down-down-down to hell.

The doors opened and she found herself stepping out onto the putting
green of a beautiful golf course. In the distance was a country club
and standing in front of her were all her friends - fellow executives
that she had worked with and they were well dressed in evening owns
and cheering for her. They ran up and kissed her on both cheeks and
they talked about old times. They played an excellent round of golf
and at night went to the country club where she enjoyed an excellent
steak and lobster dinner.

She met the Devil who was actually a really nice guy (kind of cute)
and she had a great time telling jokes and dancing. She was having
such a good time that before she knew it, it was time to leave.
Everybody shook her hand and waved goodbye as she got on the elevator.

The elevator went up-up-up and opened back up at the Pearly Gates and
found St. Peter waiting for her.

"Now it's time to spend a day in heaven," he said. So she spent the
next 24 hours lounging around on clouds and playing the harp and
singing. She had great time and before she knew it her 24 hours were
up and St. Peter came and got her.

"So, you've spent a day in hell and you've spent a day in heaven. Now
you must choose your eternity,"

The woman paused for a second and then replied, "Well, I never
thought
I'd say this, I mean, Heaven has been really great and all, but I
think I had a better time in Hell."

So St. Peter escorted her to the elevator and again she went
down-down-down back to Hell.

When the doors of the elevator opened she found herself standing in a
desolate wasteland covered in garbage and filth. She saw her friends
were dressed in rags and were picking up the garbage and putting it in

sacks.

The Devil came up to her and put his arm around her. "I don't
understand," stammered the woman, "yesterday I was here and there was
a golf course and a country club and we ate lobster and we danced and
had a great time. Now all there is a wasteland of garbage and all my
friends look miserable."

The Devil looked at her smiled and told...

-

-

-

"Yesterday we were recruiting you, Today you are an employee."

Breakfast - 2 egg omlette (1.2 carbs), 1 oz cheddar cheese (1 carb)

Total - 2.2 carbs

Lunch - 1 cups spring mix (1 carbs), 1.4 cup cauliflower (0.7 carbs), oil and vinegar dressing, handful of pork skins, 3 stuffed mushrooms (5 carbs)

Total - 6.7 carbs carbs

Snack - 4 large pepperoni slices, few pork skins with 1 tbsp sour cream (1 carb) and 1 tbsp verde salsa (0.5 carbs)

Total - 1.5 carbs

Dinner - 3 oz can tuna, 1 cup mixed greens (1 carb), 1/4 cup grape tomatoes (2 carbs), 1/2 cup spinach (0.4 carbs, 1/2 oz blue cheese (0.5 carbs), sprinkle of bacon, olive oil and vinegar dressing, 1 tbsp lemon juice (1 carb)

Total - 4.9 carbs

Daily total - 15.3 carbs

Newcomb’s paradox has it that an accurate prediction is made of your future behaviour upon entering a room and being presented with two options. If it is predicted that you will take both $1K and an opaque box, then nothing will have been deposited in the latter. If it is predicted that you will take the opaque box alone, then $1M will have been deposited therein. What should you do?
I will consider the paradox pragmatically, in terms of whether or not our predictive capacities could ever become accurate enough to warrant the apparent game-theoretic disadvantages of abandoning the certainty of (a possibly extra) $1K.
Leaving aside the difficulties presented by Physics (Quantum or otherwise), the scenario remains metaphysically problematic insofar as the participant in the scenario is informed of the prediction (and their freedom thereby called into question). Were they not so informed, then, taking the $1K in addition to the opaque box would obviously be the reasonable option. However, I shall argue that, with advances in Empirical Psychology, these difficulties can be overcome so that taking the opaque box alone must be the right choice. This is possible in that the scenario forms a closed system, where the predictor’s interaction with any participant is predetermined and invariable.
The mistake made by those who take both boxes, then, is to think that the predictor’s interaction somehow ‘opens up’ the system; for, if it were to, then, quite rightly, it would indeed render the possibility of such a ‘prediction’ metaphysically impossible.
In conclusion, then, Newcomb’s paradox is rendered ineffectual in addressing questions of metaphysical freedom.

1. INTRODUCTION

To refresh our memories of what it is exactly we mean by Newcomb’s Paradox, allow me to reiterate the account given in the abstract to this paper:

Newcomb’s paradox has it that an accurate prediction is made of your future behaviour upon entering a room and being presented with two options. If it is predicted that you will take both $1K and an opaque box, then nothing will have been deposited in the latter. If it is predicted that you will take the opaque box alone, then $1M will have been deposited therein. What should you do?

I suspect that most people, upon first encountering this scenario, will typically trust the assurance that the predictor is accurate, and, so, will readily pass up the certainty of the supposedly ‘extra’ $1K. Indeed, from my own experience, even those who eventually come to decide that taking both boxes maximises the expected outcome, usually do so only after they’ve had the paradox laid out in front of them.

So, how do we ‘lay out the paradox’? Well, it usually takes the form of pointing out that, at the point in the scenario where one is making their decision, the opaque box either contains $1M or it doesn’t, and there is nothing one can do now to change that; for all parties agree that there is no reverse causality. At this point, then, game-theoretic tables are usually drawn up …

2-boxer    $1M    $0M
2-boxer    $1.001M    $1K
1-boxer    $1M    $0

… such that taking both boxes seemingly maximises one’s expected utility, because, regardless of whether or not the box is empty or full, the 2-boxer will be ahead of the 1-boxer by $1K.

1-boxers, however, will typically want to draw up their tables …

Correctness Dependent    ✔    ✖
2-boxer    $1K    $1.001M
1-boxer    $1M    $0

… according to whether or not the prediction was correct or not. 2-boxers may still happily accept this table, claiming that, overall, taking both boxes results in the higher expected outcome.

In order to counter such a move, 1-boxers must reflect …

1-boxer    ✔ (x1)    ✖ (x0)
2-boxer    $1K    $1K
1-boxer    $1M    $0

… what they take to be the expected likelihood that the predictor will be right rather than wrong. In this case, the 1-boxer is clearly way ahead of the 2-boxer, because, for the 1-boxer, the predictor being wrong is out of the question.

Leaving aside the ‘correctness-dependent’ table, I wish to consider a number of different arguments as to why a 2-boxer might believe that the 1-boxer table is untenable. I shall conclude that none of the arguments that will be considered here today are able to undermine what I take to be the only 1-boxer argument possible.

2. INDUCTION

As far as I know, all of the various Newcomb scenarios are careful to stipulate that the scanner’s predictive capacities are, prima facie, accurate enough to outweigh the game-theoretic disadvantages of leaving the certain $1K by the wayside. That is, if we wholeheartedly ‘trust’ the predictive accuracy of the scanner to be 100%, then, according to the option we take, the respective presence or absence of the $1M is held to be just as certain as the converse loss or gain of the $1K.

I believe that the only argument that a 1-boxer can offer for such wholehearted trust in the stipulated accuracy of the predictor must ultimately rest on inductive evidence.

Imagine, for instance, that, prior to your ‘live run’ through the Newcomb scenario, you were allowed to conduct as many experimental, ‘practise runs’ as you wished, with as many different participants as you could muster. Imagine, further, that, although you couldn’t exactly figure out how the predictions were being made, each and every time, no matter how you tried to throw off scanner’s predictions, (each and every time) it was correct in either depositing or refrained from depositing the $1M in the opaque box.

Now, although you might not be able to exactly figure out how the predictions were being made, if it was clear that they were being made according to some mechanical process that was directly responsive to the empirical data collected by the brain scan, such that you had no reason to believe that it would respond to the live run any differently than from all of the practise runs, then, when it actually came to the live run, it would be irrational to try your luck in shooting for the extra $1K. Inductively, the opaque box alone would be the safe bet.

Obviously, the Newcomb scenario, as it is normally given, does not allow for such experimentation. The participant’s live run is their first and only turn, and there is nothing in the script of the scenario to suppose that they had any inkling of such a game or such high predictive capacities ever before.

I think it would be mistaken, however, to suppose that the crux of the Newcomb paradox could be merely a matter of the participant’s gullibility. Obviously, if any of us were to find ourselves presented with the Newcomb scenario sometime later today, it would be ridiculous to trust the claim that the present day’s technology could produce a prediction as accurate as is claimed by the scenario.

The Newcomb Paradox, however, is a idealised thought-experiment, unconstrained by real-world pragmatic considerations, such as technological developments. If the scenario stipulates that the scanner’s predictive accuracy is 100%, then those who decide to trust or believe in such claims are not to be uncharitably dismissed as naively gullible.

Therefore, even though the scenario as we encounter it, does not permit the 1-boxer the inductive – even scientific – experimentation suggested, for the 1-boxer position to be in any way tenable, they must, as I see it, indirectly trust that the stated predictive accuracy had been rigorously arrived at via a process of scientific induction. Just as the majority of us do not conduct our own scientific investigations, we are nonetheless rationally justified in trusting the claims of those who do. As Raimond Gaita put it: ‘It would be insane to actually think that a chef in a restaurant might have poisoned our meal.’

If the 2-boxers are right in their thinking about the Newcomb paradox, then they must show how the perfectly sane trust that 1-boxers have in induction can be undermined. But, as I just mentioned, it is not enough to suppose that the 1-boxers’ trust is misplaced, say, because the predictive accuracy was deceptively overstated. Rather, the burden falls on the 2-boxers to prove that there is necessarily some reason why the predictive accuracy could never be high enough to outweigh the comparative certainty of the $1K.

3. RELATIVE CERTAINTIES

At this point, a 2-boxer may be tempted to argue from the relative strengths of inductive and deductive certainty. That is, while the scenario stipulates that the prediction is 100% accurate, this may be thought to pale into insignificance given the comparative strength of 100% certainty of winning the extra $1K (see 2-boxer table).

Many, I suspect, would argue that the latter admits no lesser degree; any given deductive matter is either wholehearted true or false, and nothing in between. However, issues of vagueness aside, I think the real distinction is to be made between the retrospective nature of inductive reasoning, compared to the apparently atemporal nature of deductive reasoning. If inductive certainty is weaker than deductive certainty because of its dependency upon data derived from the past (or, at most, the-present-become-past), which future events may unexpectedly overturn, then, this ought to be reflected in the language. When the Newcomb scenario makes the two statements regarding the accuracy and certainty of the prediction and the $1K, if inductive certainty is weaker than its deductive counterpart, then the statement of the scenario should clearly reflect that.

However, putting this concession aside, even so, I do not believe that the comparative deductive certainty of winning or losing the $1K is enough to outweigh the benefits of gaining the $1M if (and I stress, ‘if’) it could be honestly or scientifically said that the prediction was 100% accurate. While, I am happy to admit that humanity’s inductive certainty is still a long way off from the 100% mark, still, even now, inductive reasoning manages to get us happily through most of our days with just as much success as does our deductive reasoning.

This is especially pertinent considering that our everyday deductive processes also rely heavily on. For instance, when calculating in your head the sum of two numbers, the happy feeling that tells you that you’ve made the right connection and arrived at the correct answer is in no way deductive.

4.0 GETTING A GRIP

There are, then, generally speaking, two legitimate approaches a 2-boxer might take in attempting to refute the claim that the accuracy of the predictor could ever attain a degree high enough to outweigh the certain loss of the $1K. I call these approaches ‘grip’ and ‘slip’.

By ‘grip’ I refer to the possibility of certain metaphysical limitations constraining our predictive capacities. If the Newcomb Paradox can be shown to fall outside of these parameters, then the 2-boxer will have grounds for distrusting the stipulated accuracy of the scenario.

By ‘slip’ I refer to certain arguments that claim our inductive capacities could never reach anywhere near the 100% mark. Although, as I have argued in the last section, I do not believe that this in itself would show that the relative certainty of inductive reasoning could not outweigh the loss of the comparatively small extra $1K, at least it would give the 2-boxer grounds for disagreement.

I will start by trying to get a grip.

4.1 GOOGLEME

Most will be familiar with the ever-increasingly wide range programs that the internet search-engine Google offers, such as GoogleScholar, GoogleEarth, GoogleSky, GoogleMars, etc. Imagine, then, that, one day, Google were to release a program called ‘GoogleMe’, devoted entirely to the ultimate social taboo of googling oneself. (Tell me you haven’t done it.) Imagine, then, guiltily sitting down at your computer to indulge in googling yourself, only to find that, in addition to all the biographical details of your past life, there was a shiny new, blue hyperlink called ’10 seconds into your future’. Curious you open the link to reveal the words, ‘You willing poke yourself in the eye with your finger.’ What do you do?

4.2 FUTURIST EXAM PARADOX

Another thought-experiment that I think helps illustrates this notion of grip, I know as ‘The Futurist Exam Paradox’. It goes like this:

Imagine that Futurism (the practise of predicting the future, normally with regard to technological developments and sociological trends) were one day to become a widely accepted sub-school of university History departments, such that undergraduates would have to take end-of-year Futurism exams where they would be called upon to make informed predictions regarding the future. In such a world, there would surely arise the urban myth of a more-than-usually-eccentric Futurism professor who set an exam with only the one question: ‘Will you pass or fail this examination?’ While students who confidently answered ‘pass’ could happily and unproblematically be awarded a passing grade, the more self-deprecating students who answered ‘fail’ would present the examining professor with something of a paradox: if he failed them, then their answers were right and so they should deserve to pass, which would in turn make them wrong, and so they should rightly fail, which is what they predicted in the first place … and on and on to infinity.

***

Both of these thought-experiments go to show that there are certain predictions that cannot be stated either consistently or coherently; that is, without incurring contradictions. This, however, is not to say that the ability to predict the future is necessarily limited. Rather, it is a restriction on our predictive capacities only insofar as making a prediction is propositional; the limitation is thus only on how and to whom the propositional prediction is made. As Dostovesky’s Underground Man put it:

…even if man really were nothing but a piano-key, even if this were proved to him by natural science and mathematics, even then he would not become reasonable, but would purposely do something perverse out of simple ingratitude, simply to gain his [sense of freedom].  And if he does not find means he will contrive destruction and chaos, will contrive sufferings of all sorts, only to gain his point!  He will launch a curse upon the world, and as only man can curse (it is his privilege, the primary distinction between him and other animals), may be by his curse alone he will attain his object--that is, convince himself that he is a man and not a piano-key!  If you say that all this, too, can be calculated and tabulated--chaos and darkness and curses, so that the mere possibility of calculating it all beforehand would stop it all, and reason would reassert itself, then man would purposely go mad in order to be rid of reason and gain his point!

4.3 RHETORICAL DECEPTION

To put it another way, let us briefly consider the necessity of deception in the art of rhetoric.

Roughly speaking, rhetoric – the art of persuasion – seeks to know, for any desired effect, E, to be brought about in a specific audience, A, what utterances, U, must be made by a particular speaker, S.

Socrates frowned upon the orators of his time, arguing that the ignorant nature of the masses meant that the most effective utterances tended unduly towards flattery and, so, away from the truth. In light of the above thought-experiments, however, we can strengthen Socrates’ criticism, arguing that deception must be an inescapable component of any prescriptive art of persuasion. That is to say, if a speaker desires that effects of a certain kind be brought about in their audience (for example, intentionally having the audience rile against what they are told by the speaker), then it will be required that the truth of the prediction not be conveyed to the audience, in order to avoid the difficulties of contradiction that we encountered in the GoogleMe and Furturist Exam examples.

I think Socrates would rightly deem such an occupation to be intrinsically ignoble. Furthermore, although there are many other reasons in addition, I think that this condition in itself rightly precludes Rhetoric from ever becoming a science … at least as Rhetoric has been traditionally conceived. For it is, however, possible to imagine an Art or Science of Rhetoric belonging to the ever-increasingly-rigorous discipline of Empirical Psychology, where the prescriptive element of desired effects would be made anathema, so that only the descriptive element remained. That is, the new Rhetorical program would be to learn and understand the probable effects (desirable or not) on any given audience as caused by any given utterances made by any given speaker.

If we think about this in the context of Newcomb’s Paradox, we see that it is not the intent of the scanner’s informing the participant of their situation and options to bring about any particular outcome. It would, however, be easy to imagine a version of the Newcomb scenario where the predictor did employ rhetoric so as to increase the supposed ‘accuracy’ of its so-called ‘predictions’. Indeed, I suspect, at this superficial level, you and I could readily ‘predict’ the majority of people’s choices to a fairly high degree, such that placing the $1M in the opaque box would almost always be the safer option, except perhaps when you sized someone up as looking particularly greedy, calculating or philosophical.

All of this, I believe, amounts to a failed attempt at getting a grip on the prediction made, so as to be able to thwart it by contradicting it. That the participant is informed of the prediction, and their metaphysical freedom thereby thrown into question, is not in itself enough to get a grip … unless, of course, one were to take the path suggested earlier by Dostoyevsky’s underground man, where one might introduce some external influence, like alcohol, concussion or flipping a coin, ‘in order to be rid of reason’ so as to ‘gain’ one’s freedom. But, to take such a line (like trying to opt for the $1K alone), would be to merely avoid the question posed by the Newcomb scenario; and we want answers.

5.0 LETTING IT SLIP

The other general approach that I suggested earlier, I called ‘slip’. With ‘grip’ the idea was that the prediction made by the Newcomb machine might allow the participant to somehow contradict it. With ‘slip’ the thought is that the predictor itself might not be able to sufficiently grasp the participant’s future thoughts or behaviour in order to make the prediction as accurately as is stated in the scenario as it is given.

5.1 THE GRANDMASTER LIMIT

I suspect that the favoured slipping point in the Newcomb Paradox is thought to arise because, although the scenario stipulates that prediction is incredibly accurate, people tend to believe that their decision must ultimately remain undetermined until it is consciously made and acted upon. What I call ‘The Grandmaster Limit’ clearly illustrates this idea:

We can, I think, happily imagine a chess Grandmaster easily and accurately predicting the future moves of a lesser opponent (say, of a child). However, just as it is inconceivable to imagine an inferior player ever being able to accurately predict (without external assistance) the moves of a Grandmaster, so too is it incoherent to suppose a Grandmaster being able to accurately predict their own moves without simultaneously making them. The Grandmaster stands at the pinnacle of chess playing ability, such that not only is it impossible that another other human could accurately predict their next move, but not even they themselves could, because any such prediction, known to be accurate, would be indistinguishable from the decision itself; the two would inevitably collapse into one.

In this light, we can be sure that there is no possibility of the Newcomb predictor being able to accurately predict what it’s own prediction will be.

***

If, as I suspect, something like this constraint of subjective epistemology is what motivates some people’s inclination to discount the stipulated accuracy of the Newcomb prediction, then, Turing’s Computing Machinery and Intelligence is pertinent here:

We like to believe that Man is in some subtle way superior to the rest of creation. It is best if he can be shown to be necessarily superior, for then there is no danger of him losing his commanding position.

But, as Turing pointed out, although we are all guilty of such thinking at times, in reality it amounts to little more than anthropocentric arrogance, for there is, as yet, no metaphysical reason why another intelligence, such as that of the Newcomb predictor, could not be so far superior to our own, that all of our most sophisticated intellectual twisting and turnings, would be, for it, as straight as a line between A and B.

5.2 CHAOS THEORY (& THE MONTY-HALL PROBLEM?)

Still, some may be tempted to argue that Chaos theory, and not blind anthropocentricism, can be invoked as excluding the possibility of a prediction concerning human thought and behaviour ever reaching anything near 100% accuracy. As it was sold to me by Alan Hazen, Chaos Theory claims that even in a relatively simple system, the effects of even the most negligible elements (think ‘butterfly’) can be so far ranging, that to calculate from one moment to the next would take longer than the entire history of the universe.

So, in the brain of the participant in the Newcomb scenario, between the moment their brain is scanned and the moment they decide to take either one or both boxes, the vastly complex of interactions, not only between neurons, but even between (and within?) quantum indeterminate atoms will result in what is called a chaotic system that could never be 100% accurately predicted … especially not in the short time it took the predictor to scan and deposit or not deposit the $1M in the opaque box (remember that the money has to be either there or not there when the participant is informed of their situation).

Take the Monty-Hall Problem as illustrative of this point: Normally, you have a one-in-three chance of choosing the right door. When the game-show host shows that the prize is not behind one of the two doors you didn’t choose, then offers you the opportunity to change to the other unopened door, probability suggests you should change so as to increase your chances to two-in-three.

M-H    Door 1    Door 2    Door 3    Result
Option 1    $        ✖    ✖
Option 2    $            ✔
Option 3    $            ✔

Legend:
$ - money         - first choice     - door opened
 - final choice    ✖ - lose        ✔ - win

But, while statistical probability assures us that taking the opportunity to change doors is the rational move to make, such that if you had an infinite amount of turns at the Monty-Hall game, your winnings would tend towards 2 out every 3 games, as opposed to the 1 out of every 3 expected winnings if you sat still, given that you only have the one live run (similar to the case of the Newcomb Paradox) a person may wish to remain true to their first choice, because – they might argue – the money is either behind the door that they’ve chosen or it isn't, and moving doors isn’t going to change that.

This may seem a little unfair, but I think we can try to motivate it a little more charitably. Imagine that the Monty-Hall Problem had, not a mere 3 doors, but an infinite amount of doors to choose from. As the number of doors increases to infinity, the advantage of changing doors decreases, given that the game-show host has more and more options of which empty doors to open. In the original 3-door scenario, the game-show host’s hand is forced, as it were, to show you that the money is not behind one of the door’s you neglected to choose. As it’s more likely that you chose the wrong door in the first instance, it is more likely that the money will be behind the door that the game-show host didn’t open.  But, as more and more doors are added to the scenario, the participant is given less and less information as to which door the money is more likely to be behind, such that, if the scenario consisted of an infinite number of doors, for the game-show host to open one of the infinity of empty doors that you didn’t choose, provides you with absolutely no incentive to change from your original choice; it’s as likely to be right (or wrong) as it was in the first instance.

Now, a participant in the original Monty-Hall Problem, who refuses to regard themselves as a statistic and chooses to throw probability to the wind, may do so on the belief that the chaotic universe which brought them to make their initial choice, requires that it ought to be treated as though it were one of an infinite amount of possible doors, and, so, there is nothing to be gained from changing doors, for either the right door has been chosen, or it has not.

Obviously, this would be irrational, but, when we transfer the same notion across to the Newcomb scenario, we see, I think, that a similar line of thinking must be appealed to if it is to be this notion of ‘slip’ that we’re working with, that permits the 2-boxer’s supposed V-rationality to fly in the face of the stipulated accuracy of the prediction. That is to say that, given that the single-state prediction was derived from a chaotic system which renders our finite brain-cells to be something akin to an infinity of doors, the 2-boxer’s appeal to deductive reasoning is, as if to deny the very meaning of a so-called ‘prediction’ having been made.

If this is the 2-boxer’s grounds for adopting their form game-theoretic decision making process, then, again, I feel that it is somewhat unexpected. 2-boxers typically regard their ‘V-rationality’, as Lewis labelled it, to be more straight-forward than the 1-boxer’s hand-wavey ‘U-rationality’. Therefore, I do not think that this is the point the 2-boxers want to make; it may give them ground for disputing the 1-boxers choice, but at too high a cost.

As I pointed-out earlier, the Newcomb paradox is a Philosophical thought-experiment. Chaos Theory belongs to Physics. While some may wish to argue that our metaphysics should be supplicant to the sciences, at present there are no such constraints. Obviously, if Chaos Theory is correct, then we will never encounter a Newcomb predictor capable of making the claims that are made in the thought-experiment; it’s pragmatically impossible for us to make use of more than all the time in the history of the universe to make our calculations. But this doesn’t mean that speculatively, this is the case. Metaphysically, some may wish to argue that, although practically no such prediction could ever be made in real-life, prima facie that doesn’t mean that there’s no sense in thinking about the scenario for what it might reveal about our decision making processes and our understanding of our metaphysical situation.

And, even so, even if the 2-boxers were to willing to make recourse Chaos Theory, as I explained earlier, even if our inductive knowledge can never attain to the same degree of certainty that we find in deductive reasoning, the relative certainty that is available to science, even today, seems strong enough to outweigh the relatively small gain of an ‘extra’ $1K.

6. CONCLUSION

It is important to remember that the pain of childbirth is a pain with purpose, and second, that it is influenced by many factors. Like all other pain, the intensity of contractions causes pain (or intense power, according many), which is a signal to you. It is a signal to avoid injury to your body and that of your baby's. In the case of labor, the path to avoid injury is the same path by which the baby must be born. Avoiding pain by changing positions, emptying the bladder, eating and drinking, and by receiving continuous emotional and physical support will help to protect you and baby and to facilitate the natural progression of the birth experience.

Unfortunately, it is difficult to meet the requirements for natural pain relief in an environment that favors convenience and technology. It is therefore important to choose your birth attendant carefully, as well as the environment in which you will give birth.

There are some indications of when medication for pain relief may be of benefit such as: during routine procedures (i.e. restriction to bed, no food or drink, continuous electronic fetal monitoring), when labor is induced or augmented by medications which cause increased pain, back labor with a posterior baby, very long labors, and labors with a lack of continuous emotional and physical support. Though each of these may have a resolution (i.e. letting the tired mom rest, allowing her to remain out of bed, and attempting to turn a posterior baby), pain relief medications may ease the your anxiety and allow labor to progress efficiently.

However, there are risks to taking any pain medication that every mother should be aware of before accepting them. The less risky of medications are narcotics. These may take the edge off the pain but are not without side effects. Narcotics may make you and baby sleepy, resulting in an inability to handle contractions well and feeding difficulties or need for medical intervention in your baby.

The most common choice of pain relief is epidural anesthesia. Once administered, your labor will become a medical event. You are required to have intravenous fluids and continuous electronic fetal monitoring as well as restriction of movement and the increased possibility of needing a urinary catheter. An epidural may cause your labor to slow down, especially you are less than five centimeters dilated when it is administered, though for a woman who has become exhausted because of a very long labor, the epidural may allow her body to progress more efficiently. Pitocin may be required to speed up the labor. Once the second stage (pushing phase) of labor is reached, lack of feeling will prolong the birth and make it more difficult. In this situation, if you and baby are doing well, it is best to "labor down" and wait for the urge to push or until the baby's head is visible to begin pushing. This will reduce your chance of becoming overly tired and will help to keep your baby's heart rate at a normal pace.

Women who have an epidural are more likely to develop a fever after birth. If you do have a fever, your baby will likely be taken to the nursery and given and IV and a blood test to make sure he is healthy. Other risks of epidurals include: difficulty breathing and/or feeding in the newborn, increased chance of a vacuum extraction, forceps or cesarean delivery, and backache lasting for days after delivery.

Other pain relief medications include the sterile water block (for back labor, with no known side-effects) and spinal anesthesia (an injection in the spine, similar to an epidural with less of a numbing effect).

Choosing a supportive birth attendant, letting labor start on its own, staying home as long as possible and remaining active throughout labor will increase your probability of having a normal and safe delivery.

Be confident in your ability to give birth, address your fears before labor and if you need pain medication, continue to work toward as normal a birth as possible. Your efforts will bring strength to your confidence as a woman and mother. You cannot guarantee the outcome, but you can influence it, and both you and your baby will benefit.

When cesareans were first performed in the United States, a surgeon made the incision at the top of the uterus for easier delivery of the baby. Because the top of the uterus is the part that contracts the hardest, many subsequent deliveries resulted in rupture of the uterus and they bled horribly before being sewn up. Many women and babies died from this experience. That is why the term "Once a cesarean, always a cesarean" was coined (Craigin). It was just too dangerous to attempt a vaginal birth after cesarean, or VBAC.

Times have changed. Now, obstetricians, who are aware of the function of the uterus, are trained to perform cesareans. They decided it was safer to use a "low-transverse" incision (also know as the bikini cut), where the uterus does not contract as much. Since then, studies have shown that with VBAC there are less cases of rupture, less chance of hemorrhage and infection, resulting in more healthy moms and babies. Unfortunately, now that cesareans are safer and easier, doctors are relying on them more and more for their convenience and peace of mind (lest someone sue them for not getting the baby out sooner).

The World Health Organization (WHO) stated that a cesarean rate over 15% represents a danger to both women and babies. If a rate over 15% is dangerous, then we should be wondering why the United States has a 30.2% cesarean section rate (CDC, NVSR, Vol 55, No. 11, 2006). This is a record setting, and an increase of 46% in 9 years! The Maternity Center Association published an article that included several reason why our cesarean rate has been steadily increasing. These include:
* Provider's fear of lawsuits
* Forced cesareans (for women who are unable to find a supportive doctor to deliver them vaginally)
* Casual attitudes about surgery
* Growing belief that c-section is "safe" and vaginal birth is "harmful"
* Side effects of other common procedures (induction, electronic fetal monitoring, etc.)
* Failure to support normal physiologic labor

The Maternity Center Association found in their research that women who had a cesarean delivery experienced more adverse effects than women who gave birth vaginally. When comparing maternity care costs of U.S. hospitals in 2003, they found that c-sections with no complications cost on average $5,285 more than a vaginal birth with no complications. A standard vaginal birth costs about $6,239. This is their summary on the issue: "Unless there is a clear, compelling and well-supported justification for cesarean section or assisted vaginal birth, a spontaneous vaginal birth minimizing use of interventions that may be injurious ot mothers and babies is the safest way for women to give birth and babies to be born". For a full description of their research, visit the following website: www.maternitywise.org/cesarean_response.html .

The largest ever study of women who gave birth at home (Johnson, 2005) found that only 4% required transport resulting in a cesarean section. This rate and type of care placed no extra risk for mothers and babies compared to mothers and babies experiencing hospital birth. There are many differences between hospital and home births, but a 4% cesarean rate is a good goal for U.S. hospitals to attain, one that would likely take many years to develop, even with much effort.

Not only is our section rate climbing, but our VBAC rate has declined as well. It had been climbing steadily and peaked at almost 76% in 1996. It would seem that we had begun to realize the benefits of a vaginal delivery after cesarean, but now we are back to a VBAC rate of 10.6% (CDC, 2005). The reasons are similar to those listed above for cesarean births.

The Journal of Obstetricians and Gynecologists recently released a study which was conducted between 1999 and 2002, and included the cases of 14,529 women who underwent a trial of labor after a previous cesarean section. The report stated that 73.6% of these women succeeded by delivering vaginally. With the average woman having a 70.1% chance of having a vaginal birth, whether or not she had had a previous cesarean, the woman attempting a vaginal delivery after cesarean has just as good a chance of achieving a vaginal delivery as the woman who has never had a cesarean.

One of the major excuses people still use when trying to convince women that it's unsafe to have a VBAC is that her uterus could rip open in labor and that she could die from internal hemorrhage or at least lose her child. What many do not realize, or do not believe, is that if a woman is going to rupture, she will most likely do so before labor begins. Also, "it is important to remember that no uterus is immune to rupture. Rupture in an unscarred uterus is far more catastrophic for both mother and baby"¹. Why, you ask? Because with an unscarred uterus, the tear is most likely to occur at the top of the uterus, which is hardest to recover from. For a VBAC mom to have a rupture, it simply means that the previous incision will open gently and neatly, leaving a "nice" job for an obstetrician to sew up. Not only that, but Cohen and Estner also found a study of 93 rupture cases in in which two thirds of them occurred in normal uteri. There were nine maternal deaths, all in the group of women who had not had a cesarean section. They go on to say that "the incidence of fetal death with VBAC is agreed to be less than with elective repeat cesareans, even by the most reluctant VBAC skeptics"².

Advantages of waiting till labor begins to have an elective repeat cesarean include: establishing fetal maturity, the contractions stimulate and prepare the fetal lungs, the contractions thin out the uterus and minimize maternal blood loss.

"We also conclude that the rising cesarean section rate is a matter of concern. It is a matter of grave concern. The cesarean epidemic must be brought under control. Too many mothers and babies are being needlessly exposed to avoidable risks, and too many physicians are refusing to admit it. As it becomes increasingly apparent that the medical profession is not going to put constraints upon itself, it becomes more and more obvious that we, the consumers, are going to have to take control"³. This statement is as true today as the day it was made.

If you are planning a VBAC, I highly recommend two books: "Pregnancy, Childbirth and the Newborn: The Complete Guide" by: Simpkin, Whalley and Keppler (2001) and "The VBAC Companion" by: Diana Korte (1997). Learning and utilizing the information they give will increase your chances of having a successful VBAC.

Sources:
1,2 & 3 - "Silent Knife" by Cohen and Estner. 1983

What causes fear of childbirth? Most women are concerned about one aspect of birth or another, and sometimes of birth itself. The most common fears related to childbirth include pain, exposure, death, hospitals, the unknown, and the fear of not having continuous emotional support. Considering how little women are taught about the reality of birth before their first child, these fears are to be expected. In fact, they are considered natural. Let me tell you now, there is nothing natural about the fear of childbirth. If it was supposed to be that way, adrenaline and oxytocin would not be able to contradict each other. We were designed to give birth in an environment that helps us to relax and let go.

How do you prevent or remove fear from your life? The first step is recognize where fear is present in your mind. The answer may be obvious to you, or it may not. It would help to start writing in a journal about all your feelings concerning pregnancy, birth, parenting, babies, etc. Don't think about what you are writing, just write. Eventually, you may begin to see a pattern surfacing, specific concerns or fears that you don't know what to do about. At this point, it would help to speak to someone experienced in birth or in the type of fear you are experiencing. If your caregiver is pressed for time, schedule a visit with a birth doula, a birth counselor, or a therapist. Each of them can help you to discover a solution to your fear.

Most women who fear childbirth with a dread are given the option of an elective cesarean section. Because all major surgery comes with additional risks, if you fear childbirth you would benefit from trying these treatments first, and then preparing for "the C birth":

* Learn the facts. Women were designed to give birth, most complications that occur send prior warning and can be treated before a trajedy happens, and very few women die in childbirth (13 in 100,000 ³), with many of these happening because the women did not receive prenatal care. Read up on the basics of how birth works and what you can do to make it work efficiently and make it easier for you. Knowledge creates peace and preparedness, and will dispel any fears that you have made based upon misinformation.

* If you fear hospitals in general, planning a birth center birth or a homebirth with a trained midwife may be a good alternative for you. Schedule an interview with a midwife or birth center to discuss your options.

* As for pain, every woman has a different threshold. Knowing that pain medications are available to you if you need them can help to dispel the fear, but it will also help if you come prepared with natural pain relief techniques (such as water, massage, and positioning) that you can use before taking the pain medications.

* If you are afraid of having the hospital staff see you yelling, vomiting, being naked and perhaps having a bowel movement, the best reassurance is probably something you've heard before. Although this behavior is not typical of every day life, it is very normal for that of a birth attendant. Nothing you do will shock them or make them laugh. If you are still nervous, ask your husband or birth partner to try and keep you from being exposed unless necessary. You can also seek a care provider who embraces the raw power and feminine nature of birth, since they tend to make their patients feel more normal and their behavior more appropriate.

* If you experience slowed or stalled labor, it may be because someone new entered the room, a sudden noise or movement was made, or something else startled you. The adrenaline released causes the contractions to slow or stop in preparation to defend yourself. By simulating fighting off a predator, you can start your labor back up again. This is as easy as beating a pillow for several minutes.

* Listening to women talk about their positive birth experiences, reading about them, or viewing their pictures or videos are all good ways to prepare for the work of labor. They may inspire courage and create a sense of calmness about the upcoming birth.

* If you believe in God, having complete faith that He will provide everything you need to give birth, and remembering that, can encourage you to be strong.

The most important thing may be to not keep your fear to yourself. Talk to someone who can help you, your husband, family and friends may not be able to help, but an experienced mother, doula, birth counselor, midwife, or other therapist may be able to help you overcome your fear of birth. Do not be embarrassed by it, since very few women give birth in the United States without fear. It is a common feeling, but it is not necessary at birth, and in fact, birth would do much better without it.

Sources

1 - Gaskin, Ina May. "Ina May Gaskin's Guide to Childbirth" . New York: Bantam Books (2003)

2 - Wolf, Naomi. "Misconceptions". New York: Doubleday (2001)

3 - Stobbe, Mike. "Childbirth Death Rate Rises in U.S." Associated Press August 24, 2007In our day and age, there are so many different types of sources on information about childbirth that it is no wonder women can become flustered, confused, nervous, anxious, even fearful of childbirth itself. Few women witness a birth before their own time comes, and so their reference points on the challenge of labor is based on impersonal sources that women have difficulty trusting. They are left with questions unanswered, such as will I be able to handle the pain of contractions? Will I be left exposed to strangers? Or even, Will I die in birth? Most of society has ignored these conflicting feelings within women because regardless of their emotions, the baby will be delivered and the professionals will make sure everyone is healthy in the end, or at least that is the presumption. We now understand, however, that fear itself can have a negative impact on a woman's birth experience, and she will benefit greatly by learning to recognize her fears and to address them prior to labor.

If your baby is breech, you and your care provider will discuss the action that should be taken for your particular case. If you are not satisfied with his/her decision, don't be afraid to ask questions or to get a second opinion, but do try to be open to all possibilities, including both vaginal and cesarean deliveries.

The solution would be easiest if there was one clear answer for everyone - why the baby is breech, how it can be turned (if it should be turned at all), and what mode of delivery is safest. But there is no such answer. In fact, each side of the debate is backed by legitimate studies and reports. So the conclusion is to learn about breech babies, breech birth, and all your options for prevention and management. Let's start with why babies turn breech in the first place.

Throughout most of pregnancy, your baby has free range of motion and will turn somersaults - head up, head down, head up, head down - until about 32-34 weeks when he/she becomes too large for big movements like that. The baby will then naturally assume a position in preparation for birth. At term, 3-4% of babies will be in the breech presentation.

Not all babies have a diagnosable cause for being in that position, but studies have confirmed that the following conditions and situations put a mother at increased risk of giving birth to a breech baby: previous breech presentation, late or lack of prenatal care, giving birth before 37 weeks, babies with lower birth weight or with birth deformities, pregnancies with multiple babies, history of premature delivery, too much or too little amniotic fluid, an abnormally shaped uterus, a uterus with abnormal growths (such as fibroids), placenta previa, and excessive stress. Other potential causes include eating certain "yin" foods (see below), and slouching and crossing your legs consistently during pregnancy. Obviously, these risk factors do not automatically set up a woman to have a breech baby, but baby's turn breech more commonly when the mother fits into one or more of these conditions. Some of these risk factors can be avoided or corrected by the woman herself, but many require the assistance of a care provider to manage.

If despite these prevention methods your baby chooses to position itself right-side-up, here are the current methods for turning breech babies, and their pros and cons. As always, discuss these choices with your care provider before implementing any of them.

Breech Tilt Exercise. This is one of the oldest and most common methods for turning a baby in a malpresentation such as breech. With no known side-effects, this method consists of the mother lying with her hips higher than her head for 15 minutes, three times a day. This can be accomplished by resting in the air and chest on the floor. Another method is to rest with butt on pillows 9-12 inches high and back of shoulders on the floor. The last way to accomplish this exercise is to do hand stands in a pool, coming up for air frequently.

Visualizing/Hypnotherapy. Relaxation, especially when in combination with a bath, while picturing the baby moving into position has been known to work. Possibly because the peaceful feeling combined with relaxation of the abdominal and pelvic muscles allow the baby more room to move. If practicing this method, be sure not to remain on your back for too long - side-lying is a much better position. No known side-effects.

Music, Light, and Talking. Some babies cannot help but turn to face the direction where they see or hear something. Putting a flashlight, Walkman headphones, or having a loved one speak close to the lower belly may encourage your baby to turn head down.

Diet. Some call it the yin vs. yang conditions, but certain substances have been shown to encourage a breech position: cigarette smoking, stress and an overly busy life, in addition to fruit juices, tropical fruits, ice cream, sugars, oil, coffee, sweeteners, drugs, and chemicals. Foods that reportedly encourage a vertex (head down) position include animal proteins and miso which can be taken as a soup or tea.

Homeopathy. The homeopathic remedy Pulsatilla can be used in the 35th week of pregnancy to turn a breech baby, especially if the situation is stress related. However, not all women are advised to try this method, so speak to your care provider first. When using any homeopathic remedy it is safest if you work with a skilled homeopathic provider to determine the correct potency and frequency of treatment for you.

Webster's Technique. This is a chiropractic technique used to ensure optimal alignment of the woman's spine and pelvis by means of minimal pressure on a certain abdominal trigger point. According to one study, the Webster technique resolves breech presentations in 92% of cases (International Chiropractic Pediatric Association), and has been found to be helpful with other malpresentations. Because all trigger points in the body are very sensitive, and can be used inappropriately and dangerously, it is important that you use a skilled and qualified practitioner.

Acupuncture, Acupressure, and Moxibustion. The acupuncture point (Bladder 67) can be triggered by acupuncture, acupressure, or moxibustion to turn a breech baby. Although proven to be helpful, these methods can be harmful if misused, so only have them performed by a qualified acupuncture professional, after getting the approval of your care provider. Estimates of success range from 50-84%¹.

External Cephalic Version. This is the most invasive method of turning a breech baby, and is safest and most likely to be successful, if performed by an experienced doctor. The procedure is carried out by manually rotating the baby from the outside of the abdomen, usually around 37 weeks of pregnancy. Depending on how many babies the mother has had, and the experience of the doctor, success rates vary from 50-90%, with the chance of success being greater to mothers who have delivered vaginally before. Although rare, performing a version can result in the placenta tearing away from the uterus. Thus it is best to use this technique as a last resort, and with an experienced doctor, in the hospital.

Ask Yourself, Why? Exploring your thoughts about why your baby is breech may bring up strong feelings about the upcoming birth, anxiety about parenting, or a sense that your baby is not quite ready to be born yet. Although such exploration has not been thoroughly studied, anecdotal evidence suggests that it may be helpful in turning a breech baby. Even if it doesn't help your baby to turn, it may help you to feel more confident in your attitude and preparation. Your care provider may be open to discussing this question with you as well.

If after trying multiple techniques to move your baby to a vertex presentation are unsuccessful, it may be best to prepare your heart for a breech delivery. Changing plans, and adjusting to a difficult situation, are not easy, so take the time to relax, research your options, and visualize the birth of your child.

Until 1959, it was routine for all women with breech babies to deliver vaginally². Since then, studies have been published to determine whether all breech babies should be born vaginally or by cesarean, or if each case depends on specific guidelines. Only three large scale, randomized controlled studies have been published comparing mode of delivery for breech babies.

The first two studies, Collea et al. 1980, and Gimovsky et al. 1983, both stated that vaginal birth for breech babies was safe in most circumstances. The third study (published in 2000) was most interesting because it stated that planned cesarean sections were safest for full-term singleton breech babies born to first-time mothers³.

Although the 2000 study seemed conclusive, and doctors all over the United States began practicing under the influence of this study, long-term follow-up of the babies in that study led researchers to question it's conclusion. As a result, more studies and more reports have been made on the subject. In July 2006, ACOG issued a new Committee Opinion. It stated that some women may be better off planning a vaginal birth, as long as they have a care provider who is experienced in delivering breech babies vaginally, and that they were told that the risks to her baby might be higher than with a planned cesarean delivery⁴.

Despite the allowances made for vaginal breech birth, it is still difficult for women to make plans for this mode of delivery. This is mainly because doctors and midwives skilled in vaginal breech birth are getting hard to find. In 2003, only 12.8% of breech babies were born vaginally⁵. Hope remains, however, for women who are determined. Those that meet the generally accepted guidelines are able to find a care provider, even if it does mean traveling to a different location to give birth.

Here are the guidelines for being eligible to have a vaginal breech birth: Baby is full term (not less than 37 weeks), baby appears to be average sized and has no known congenital defects, mom has delivered vaginally before, or is determined to have a large enough pelvis, a doctor or midwife experienced with vaginal breech birth is managing your care, baby is in a frank or complete breech position (not a footling), baby's head is in a flexed or military position (not tipped back), mother has had no more than one previous cesarean, if mother is carrying multiples, the first baby presenting must be head down, mother is confident in her ability to give birth to a breech baby, an emergency cesarean and anesthesia are available, no induction/augmentation drugs are used, more frequent monitoring of the baby's heart rate is done during labor, labor progresses normally (at least a 1/2 cm per hour in the active phase), cord does not prolapse, and baby is not distressed in labor, no epidural is used, mom waits to push until fully dilated, mom does not push in the lithotomy or semi-sitting positions, and forceps are only used in an emergency.

Some care providers may offer you obstetrical care even if you don't fit into all of the above guidelines. If that is the case, it is wise to ensure that an emergency care plan is prepared well in advance of labor.

Even though different organizations are continuing research in this area, it remains that no definitive answer is available for all women who have a breech baby. Thus it is left up to each mother and care provider to review the information available and to make a decision based on the mother's health and preparation.

Sources:
1 - The Whole Pregnancy Handbook by Joel M. Evans, MD, OB/GYN
2,5 - "Breech Presentation" July 2006 www.emedicine.com/med/topic3272.htm
3,4- "Breech Birth" March 2007 www.babycenter.com
"Encouraging a Breech Baby to Turn" by Donna Broderick, Midwives of Maine Newsletter Winter 2005
"Breech Births Without Surgery" by Michelle Bitoun Blecher, Parenting Magazine March 1995