Tales of Birth Reframed: Part 1 – The Tale of Friedman’s Curve

Once upon a time, there was a Doctor of Obstetrics named Dr. Friedman, and he worked in the 1950s in the USA.  In this time of birth work, many of the white women delivering babies gave birth while completely unconscious in what they called Twilight Sleep.  Twilight Sleep allowed them to not remember birth very well (although the body was still laboring and would have cellular memory).   During this time, after a question posed by anesthesiologist Dr. Virginia Apgar regarding how pain relief would possibly alter the course of labor, Dr. Friedman decided to do a research study.  In his study, he took 500 women (n=500) and decided he would do a bunch of vaginal exams to collect data points as to how fast each of them dilated in labor.    The data included an age range between 13 to 42 years old, four sets of twins, and 4 stillbirths or newborn deaths. 

Of course, Dr. Friedman found quite a range of dilation in his research.  From his study of 500, he measured how many cm they dilated as they correlated with time.  He found that the average in this study was to dilate slowly to 4 cm and then dilated 1 cm an hour and then push out the baby (in three hours or less).  And then he found that some who came in, they quickly dilated and had their baby.  Maybe they were the ones arrived in triage and barely made it to the room or delivered on the elevator.  Then there were also people who slowly dilated to 4 cm and then continued to labor for days before they eventually had their baby.  Of course, they were also not eating or drinking during this time period, so we do not know what would have happened differently if they did.  This data point curve of information presented the spectrum of time and dilation and recorded the “average” results for hours to full dilation and eventually birthing.

What happened with this study is that it became the hallmark for interventions in modern day obstetrics.  The subset of the average length for dilation and birth suddenly was seen as not just being “average,” but “normal.”  And with many things in this society, there was a movement towards making labors stay “normal.”  How does one shift a labor to being in this range of normal?  How does one decrease the length of labor and move it into the curve?  

This use of the vaginal exam for dilation was soon used as the largest marker for implementing interventions and correcting what Friedman later defined as specific labor disorders.  Although in his initial notes on progress, Friedman also collected information on station and frequency of contraction, because there wasn’t a bell curve associated with these, they were not part of what would eventually become reasons for interventions.  This study has led down the pathway towards a cervical centric paradigm.

Midwives have also recognized that irregular labor patterns that might lead to longer labors can be cared for not just with hydration and nutrients (and balancing rest and activity) but also with positioning during labor that could facilitate better fetal positioning.   Information through midwives and groups like Spinning Babies™  are shifting the conversations as labors are more complex than just using dilation as the primary data point.  

First,  let’s appreciate that birth is not a one size fits all experience.  One persons “normal” is not going to be another’s.  However, we do know that when help is desired or that there is a need to prevent exhaustion, we do have a larger tool subset than just dilation.  Dilation may occur even when a baby isn’t descending.  Of course, it could be the other way around if there is an issue such as scar tissue.  But most of the time, however, when there are challenges, rather than making something go faster with force and affecting the cervix, we can find solutions through balancing the body and creating space for the baby to be born vaginally.  Balance, gravity, and movement can be used in response to external cues.  

So do we throw the baby out with the bathwater?  Yes, we do.  It is time to ask new questions and not use outdated tales that are used to determine multiple interventions that drive up the cesarean birth rate.  

What about the women who birthed quickly and yet weren’t “normal?”  I was contemplating these women and thinking that they weren’t affected by the cascade of interventions that used Friedman’s Curve as a justification.  But as a student in my workshop pointed out, there is another study that may be doing just that.  With the new Arrive Study that is pushing for inductions at 39 weeks for everyone, we can see just that.  We can push people who might birth quickly into the category of the “normal” time period via induction whether the body is ready or not.  However, some, if this is done, may not even make the curve naturally and birth by cesarean.  

Obstetrics has now acknowledged that the modern day birther gets an extra hour per cm and an extra hour for pushing.  This is still the old paradigm.  How did the measurement of the cervix in this study become the way every birth became reported?  This outdated paradigm has seeped into textbooks, curriculum, medical and midwife peer reviews, Facebook posts about births by parents and is across most mainstream charting.  

This is an old story that is still alive today until we begin to tell a new one with new questions.   Questions like “Where is the baby in the pelvis?” or  “Where are the restrictions for descent?  or “How do we reduce the diameter of the baby or open the space available?”  “What have they eaten and how recently?”  “Can we balance activity with rest?”  “How can we support this family emotionally?”   “Are we present as caretakers?”  “Do they have the support that they need or desire?”   

Friedman, “Primigravid Labor: A Graphic Costatistical Analysis?   Obstet Gynecol. 1955 Dec;6(6):567-89. 

Laughon SK1, Branch DW, Beaver J, Zhang J. “Changes in Labor Patterns over 50 Years”  Am J Obstet Gynecol. 2012 May;206(5):419.e1-9. doi: 10.1016/j.ajog.2012.03.003. Epub 2012 Mar 10.

Dekker, Rebecca Friedmans Curve and Fetal Death: The Leading Cause of Unplanned Cesareans”   https://evidencebasedbirth.com/friedmans-curve-and-failure-to-progress-a-leading-cause-of-unplanned-c-sections/   April 26, 2017.

Romero, Roberto.  A Profile of Emanuel A. Friedman, MD DMedSci.  American Journal of Obstetrics and Gynecology. October 2016. 413, 414.  https://www.ajog.org/article/S0002-9378(16)30469-0/pdf

#cervixcentric #stagesoflabor #shifttheparadigm #talesofbirthreframed