Friday, May 19, 2006

The Friedman curve

I have noticed a great deal of misunderstanding in the homebirth community about the Friedman curve, what it is, how it was developed and what it means. That is a shame because homebirth advocates share more with Dr. Friedman than they realize.

I happen to know quite a bit about it because I trained with Dr. Friedman himself. To say it was not a pleasant experience, is a gross understatement. Nevertheless, I would acknowledge Dr. Friedman as the greatest obsetrician of modern times, if not of the entire history of obstetrics. Why? Because he was one of the first to clearly articulate the idea that obstetrics MUST be based on science.

Dr. Friedman did his residency in the 1950s. He was not a man to suffer fools gladly and he considered a lot of his superiors to be fools. He felt that they made medical judgments based on their intuition and not on science, and he set out to accumulate the research data necessary to give the profession a firm scientific foundation.

During his residency, when he was on call every other night, he used his "spare" time to compile detailed observations about every laboring woman who came through the hospital. The goal was no less than to find out what normal labor looked like. Using observations from tens of thousand of women, he created a curve. Women who followed the curve were almost certain to have a vaginal delivery. Women who fell off the curve were more likely to need a C-section.

Dr. Friedman was the first to say that you should not section a woman in latent phase because a long latent phase was not a sign that the baby doesn't fit. He insisted that you should not section a woman in the active phase of labor unless she failed to make a certain amount of progress in a certain amount of time. When Dr. Friedman used to tell stories about the genesis of the curve, he would express the utmost disgust for doctors who would say, "she looks like a C-section to me".

Dr. Friedman went on to win the undying enmity (in some cases, hatred) of his colleagues because he compiled a database about forceps deliveries. He concluded, correctly, that forceps hurt babies and should be banned. He used to travel around the country testifying for the families of children who had been injured by forceps. When he would appear, the family would win.

Dr. Friedman was exceptionally difficult to work for or with, but I always admired his insistence on research evidence. We were never allowed to do social inductions, C-sections without an explicit research-based medical reason, forceps deliveries, etc.

The ultimate Dr. Friedman story was told to me by a doctor who had trained with him. At the end of his residency, after the paper describing the Friedman curve was published to great acclaim, he attended an awards banquet for the residents who were finishing the program. He was introduced with great flourish and took to the podium to say a few words. He said very few words indeed. As it was related to me, Dr. Friedman stood and said: "Thank you for the opportunity to learn so much from the patients in this program. It is a shame, however, that all the doctors are ignorant fools."

22 Old Comments:

yep I knew this about him , already made an earlier comment that he even said his information has been misused.

thank you for this info- in the 1930's sounds more appropriate in time as far as scientific research meeting the "trenches" on the job applications- but few doctors were men of science.

By Anonymous Anonymous, at 5:14 PM  

now to say something that is not about Dr. Friedman but has to do with the entire subject. I think that there is room for cleaning up midwifery /homebirth in the US- and I do believe it starts with cleaning up how the national and state stats are kept- midwives and different types of midwives need to be divided out-there is a growing movement of intentional home births that have no attendant- because midwives are considered to be to "medical" or not natural enough-- with homebirths defined between CNMs, CPMs, LMs and others or no midwife-but intentional home birth will help to figure out if there are differences ( there are some midwives who only pray at births).
additionally
each state that allows for licensed midwives also allows different kinds of bits that would be considered standard of care- some states do not allow licensed midwives to carry oxygen, IVs for fluid replacement , antibiotics for GBS prophylaxis - if midwifery stats for each state was readily available we could see if there were better outcomes in states with better access to things considered to be standard of care.
I know that your intent of this blog is to just rid the world of homebirth- but that is not going to happen- how can we improve what we do is what comes next.

By Anonymous Anonymous, at 5:48 PM  

so must have the dates off- his residency was later than that---
"Dr. Emanuel A. Friedman was born in Brooklyn on June 9, 1926. He earned a B.A. from Brooklyn College in 1947, and an M.D. from the College of Physicians and Surgeons (P&S) of Columbia University in 1951. Between 1951 and 1957, he was an intern and resident at Sloane Hospital for Women of the Columbia-Presbyterian Medical Center, Bellevue Hospital, and Francis Delafield Hospital. "

By Anonymous Anonymous, at 5:55 PM  

I know we are looking for hard data here, but I enjoy very much reading your anecdotes, Dr Amy.

By Anonymous Joanna, at 9:35 PM  

Dr. Friedman's study was in 1955 and used 500 women.

Ancient study. Small study. And the obstetrical practices of the day were quite a bit different than they are today. (twilight sleep was still being used up until 1960)

No attempt was made then, nor with modern studys, to my knowledge, to use unmedicated women. Using unmedicated women would then give results which could be used to define a normal labor curve. When inductions, augmentations and anesthesia is included in your study, your results are only applicable to that group.

By Anonymous Anonymous, at 12:28 AM  

Dr. Friedman's study was in 1955 and used 500 women.

Ancient study. Small study. And the obstetrical practices of the day were quite a bit different than they are today. (twilight sleep was still being used up until 1960)


---------------------
do I believe this or not? haven't had my hands on the study in literally 20+ years so I don't remember the particulars do you have a link ?

By Anonymous Anonymous, at 2:34 AM  

Anonymous 12:28:

"Ancient study. Small study. And the obstetrical practices of the day were quite a bit different than they are today. (twilight sleep was still being used up until 1960)"

True, but that was just the first study he did. He did many more much larger studies.

"Using unmedicated women would then give results which could be used to define a normal labor curve."

I suspect that there have been many studies done with unmedicated women. Furthermore, no one has the midwives feet nailed to the floor. If midwives think the labor curve is different for their patients, they should record it and publish the information.

Anonymous, you do something that homebirth advocates do all the time, and it destroys their credibility: you make stuff up as you go along. You have absolutely NO IDEA what studies of labor do and do not exist. Because you IMAGINE that obstetricians are evil morons, you IMAGINE that they could never have thought to do this study or that study.

Before you claim something, you should make sure it is true. Otherwise, you look very foolish indeed.

Please stop throwing mud at obstetricians, hoping something will stick, and start learning more.

By Blogger Amy Tuteur, MD, at 9:13 AM  

from a different anonymous -- there are some other studies more recent- show that average labor is a bit longer- look at New Mexico and some others.

By Anonymous Anonymous, at 10:15 AM  

"Anonymous, you do something that homebirth advocates do all the time, and it destroys their credibility: you make stuff up as you go along. You have absolutely NO IDEA what studies of labor do and do not exist. Because you IMAGINE that obstetricians are evil morons, you IMAGINE that they could never have thought to do this study or that study."

I certainly do not imagine that OBs are evil morons. I do not hate OBs. You couldn't possibly have gotten that from my post, I didn't say anything at all about OBs. I hate the Friedman curve. YOU should hate the Friedman curve. Anything that was developed so long ago, with a population of women under anesthesia known to be very dangerous to infants, should have nothing to do with the Friedman curve the way it is used in hospitals today.

Your overly hostile remark makes me wonder why you are so sensitive about this subject. I certainly didn't make up the fact that the study was done in 1955 and used 500 women. Anyone can google the information. Why the personal attack?

The reason they haven't done these studies on unmedicated women is that there aren't very many available. With a national epidural rate of 80%, And equally high augmentation and induction rates, there aren't enough unmedicated women left to do a large study on.

In one post you say you won't even discuss studies that aren't large enough to be statistically relavent, then in the next you introduce the Friedman curve. That's quite a dichotomy.

By Anonymous Anonymous, at 11:08 AM  

Anonymous:

"The reason they haven't done these studies on unmedicated women is that there aren't very many available. With a national epidural rate of 80%, And equally high augmentation and induction rates, there aren't enough unmedicated women left to do a large study on."

You are wrong on virtually every aspect in this quote.

1. Many such studies have been done.

2. The epidural rate in the US is not 80%.

3. The US is not the only country in the world. Other countries have doctors and scientists. Many have very low epidural rates. They have done studies in those countries, too.

You need to make some attempt to be sure that what you say is true before you submit it in a post.

By Blogger Amy Tuteur, MD, at 12:12 PM  

What percentage of women in US hospitals are not medicated Amy?

By Anonymous Anonymous, at 4:11 PM  

epidural in my region( I say region not city) is 80-90%
the previously midwife run unit in the county hospital was dropped their rate was 5% and they had tons and tons of walk ins w/o previous care.

i guess there could be regions that are better but mws I am in contact with are reporting similar stats in other parts of the country-- I guess we are doing our own kind of "trainspotting"

By Anonymous Anonymous, at 6:51 PM  

This comment has been removed by a blog administrator.

By Blogger sailorman, at 9:18 AM  

Sheesh.

"The reason they haven't done these studies on unmedicated women is that there aren't very many available."

Even if the epidural rate was 80%--which it is not--you're spouting nonsense.

There are about 4 million births each year.

Even if "only" twenty percent of those women were available it leaves 800,000 or so women to study.

By Blogger sailorman, at 1:48 PM  

Hi Amy,
Could you list a few of those references. I have had a horribly hard time finding good studies on natural childbirth, and research is what I do for a living. When I typed Friedman curve and natural childbirth into PubMed...I only got 1 abstract. I can't get the full article online, not even through my medical university. Here's a link to the abstract if anyone is interested. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed
Really I'd need to read the whole article to evaluate what I think of it though. The authors observe 'more variation' in the pattern of labour than was reported by Friedman, and they suggest that there should therefore, be a change to the current medical practice of time limits, especially the two hour pushing limit imposed by some hospitals.

By Blogger Dawn, at 8:27 AM  

Dawn:

"When I typed Friedman curve and natural childbirth into PubMed, I only got 1 abstract"

Try Google Scholar and look for papers on labor.

By Blogger Amy Tuteur, MD, at 9:41 AM  

I have to say I don't get much more doing that. At least not good scientific studies. There was one additional one when I dropped the 'natural' part that found epidurals lengthen Friedman curves. Not too surprising. There really isn't a lot of good research out there. If professional researchers can't find it, no wonder the general public is confused.

Dawn

By Blogger Dawn, at 10:48 AM  

Here's my question about the Friedman curve. Amy said, "Women who followed the curve were almost certain to have a vaginal delivery. Women who fell off the curve were more likely to need a C-section."

Does forcing a woman to stay on the curve with interventions that increase her chances of c-section really make sense?

By Anonymous Christine, at 2:05 PM  

Christine:

"Does forcing a woman to stay on the curve with interventions that increase her chances of c-section really make sense?"

You are misinterpreting the curve. The curve is a predictor of abnormal labor. It does not diagnose abnormal labor and you can't decide that someone needs a C-section based on the curve alone. Dr. Friedman's primary point in constructing the curve was (as I understand it) to keep doctors from performing a C-section without a valid medical reason.

Before the curve, obstetricians might estimate internal measurements of a woman's pelvis and say "she's not big enough to deliver this baby; let's do a C-section".

Dr. Friedman was saying to other doctors: you can't tell by looking and you can't tell by measuring. If a woman's labor is following the curve, there is NO REASON to perform a C-section. He always viewed a C-section as a medical procedure that should be reserved for medical reasons, not social reasons, not convenience, not anything else. It is really ironic that people view the Friedman curve as encouraging C-sections.

You can only fall off the curve if you are in active labor. That means that you must be having regular contraction every 2 minutes or so and be at least 4 cm dilated or more. Therefore, you shouldn't pit someone in early labor because a normal early labor can last up to 20 hours. If a woman is in early labor, you are not supposed to do anything.

Dr. Friedman also pointed out that if a labor fell off the curve, it was more likely to be from ineffective uterine contractions, not because the baby didn't fit. Therefore, the first thing to do would be to try pitocin. Only after a woman had good quality regular contractions with pitocin for at least 2 hours with no progress were you supposed to consider the possibility that the baby might not fit.

Dr. Friedman would be the first person to agree with you that many C-sections are unnecessary and inappropriate because the woman has never really been given a chance to labor. He would also agree with you that many women are induced inappropriately and that this increases unnecessary C-sections even further. I would agree with these assessments also.

By Blogger Amy Tuteur, MD, at 2:46 PM  

Amy on this we agree- from what I have read or heard in the past about Dr. Friedman this all fits

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