Which obstetrician was the first to oppose arbitrary limits on the length of labor?

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Can you guess who wrote this?

The usual diagnostic criteria in use nowadays invoke arbitrary standards of total duration of labor, beyond which abnormality may be considered to exist… Thus, for example, labors lasting longer than 24 hours are usually deemed to be abnormal and, therefore, to warrant consultative evaluation. This practice gained general acceptance, not so much because the criterion of duration is diagnostic (which I hasten to insist it is not), but rather because there is a relation between prolonged labor and increased fetal morbidity and mortality… [N]ot all labors which exceed these uncritical limits subject the fetus to comparable risk. The single guideline of duration, therefore, must be considered as much too coarse and insufficiently definitive to permit us to specify precisely which patients are at risk … (my emphasis)

How about this?

The physician is confronted by a wide range of normality in terms of patterns of contractility. At one extreme is the patient with negligible contractions; her cervix is dilating unobtrusively while we try to determine whether or not she is in labor… At the other extreme is the woman who suffers contractions of great intensity and frequency that may continue for many hours before cervical dilatation becomes apparent… Yet both are normal variants and the physician with enough experience will recognize their inherent differences. (my emphasis)

Or this?

Continued progress should be expected if patients with protraction disorders are properly managed in a conservative manner. The prognosis remains good as long as progress continues. There appears to be only a very small increase in risk to mother or infant from these conditions, provided no ill-advised measures for stimulation or-even more important- for traumatic delivery are undertaken. Expectancy is very strongly recommended. (my emphasis)

Or this?

Arrest of dilatation or of descent is a most serious abnormality and carries an especially poor prognosis for vaginal delivery. Many patients with these patterns ultimately require cesarean section because of disproportion. Where pelvic relations are adequate, the prognostic outlook for vaginal delivery is much better. One can determine the prognosis more carefully … if one compares the rate of progression … with the rate that occurs after treatment [with Pitocin] for the arrest… The more rapid the postarrest slope, the more likely is vaginal delivery. Patients whose postarrest slope is more than 2 cm./hr. greater than the prearrest slope should all be expected to deliver vaginally. None should require cesarean section unless it is indicated for some other reason, such as fetal distress… (my emphasis)

All of these statements come from a 1972 paper, An objective approach to the diagnosis and management of abnormal labor, by Dr. Emanuel Friedman of the eponymous Friedman Curve.

Surprised? You shouldn’t be. The new ACOG report on preventing primary C-sections is not a rejection of the Friedman Curve, but rather revisits first principles of the Curve is and how Dr. Friedman thought it should be used.

  • The Computer Ate My Nym

    My concern is in the opposite direction: C-sections were considerably more dangerous in 1972 versus now. Is waiting as long still the best approach? It might be worth looking at the rare bad outcomes in vaginal delivery and seeing if perhaps there is a situation where earlier c-section would be a better approach.

    • Amy Tuteur, MD

      It seems to me that Dr. Friedman’s key point remains the same. The Curve (adjusted for contemporary demographics) remains the best tool for diagnosing dysfunctional labor. Only REAL dysfunctional labor should be treated with a C-section for arrest; those who don’t meet the definition of arrest should not be having C-sections for arrest. That does not preclude C-section for other reasons, such as if the baby is not tolerating labor.

  • Mel

    My only concern has nothing to do with OBs. My concern is how NCBers are going to try and spin this – especially to ‘reassure’ women about questionable home birth practices.

    An OB in a hospital setting has lots of ways of measuring maternal and fetal health during labor and delivery and can identify situations where labor is longer than most other labors, but Mom’s fine and Baby’s fine so let’s keep going.

    A midwife in a non-hospital setting, though, is badly limited in terms of fetal health monitoring and some already ignore obvious warning signs – bleeding, meconium. Letting someone push for hours without monitoring the fetus – or mom – is a recipe for more HB disasters.

    Honestly, HB midwives need to realize that their situation is much closer to the obstetric situations dealt with by livestock farmers than OBs in a hospital. In the barn, we do use basic mental time tables along with what information we can glean from watching the dam and what we can see of the calf to decide what to do in terms of interventions. It’d be awesome if we could hook a cow up to a CFM or if we could do emergent CS that wouldn’t kill the dam – but we can’t and neither can midwives. Because of those limitations, responsible farmers are far more conservative in terms of risk management.

    If midwives want to truly serve women and babies, then they need to accept that a prolonged labor will require a hospital admittance.

    • Young CC Prof

      Actually, home births are exactly the situation that WHO partographs are designed for: Little technology is available, few ways to assess fetal distress, and getting to higher technology will physically take time.

      In that case, you need to use the curve strictly. If you fall off the labor curve, you start traveling towards medical technology as quickly as the situation permits, no ifs ands or buts. When you reach the technology, THEN doctors can use other factors in deciding whether or not to cut.

      • Mel

        Exactly! Dairy farmers have a similar set of time tables starting at signs of labor in the cow or appearance of amniotic sac. They are based on the fact that we have to act quickly since a slow labor may mean a dead calf.

        You should check if:
        1. The cow appears to be in labor for 12 hours without the amniotic sac appearing. (Easier said than done; cows instinctively hide any signs of discomfort or illness to cut down on being eaten by predators.)
        2. 2nd stage starts when the amniotic sac appears. Check if the 15 minute rules are broken.
        – 15 minutes after the sac appears, the front hooves should be out.
        - 15 minutes after hooves appear, the nose should be out.
        - 15 minutes after the nose appears, the head up to the shoulders is out.
        - 15 minutes after the front shoulders are out, the whole calf should be out. (We tend to intervene faster after the front shoulders are out; this is the point that the umbilical can break before the whole chest is out and the calf can suffocate.)
        3. If anything other than two front hooves and a nose appear, get help.

        In reality, on the farm, we assume a 10 minute response time for the herdsmen – basic rotations, use of OB chains and the calf puller and 45 minutes minimum for a vet to come. Long before I married my husband, he had me program the vet’s phone number in my phone and told me that if I ever had any doubts to call. Better to pay for a vet trip and have a live calf and cow than lose a calf or cow.

        Unfortunately, some farmers don’t. They mess around and wait long, long times. They tend to go out of business for two reasons – first, a dead cow is a massive waste of capital and second, good farmers don’t want to be associated with crappy farmers.

        • Trixie

          I just never get tired of your animal husbandry posts. I learn so much!

  • KarenJJ

    I’ve been reading here for a while and I know that these posts get the least traffic. As much as NCB and tone trolls say they want factual information given in a respectful way, they only really engage when you’re being more outrageous.

    But these posts I love because I find it so interesting and so reassuring that my doctors have been through this sort of training and know how to try and measure and work with biology as best they can.

    So thankyou for posting this, even if those that need to understand this and to see evidence of the process and education that obgyns go through don’t actually read it (or read it and forget about it only to pop back again in two weeks to whinge that you are meen).

  • fiftyfifty1

    Reading these quotes without reading the whole paper is confusing to me. It sounds as if he is very comfortable with protracted labors as long as baby is tolerating it well and as long as there is not a full out arrest of dilitation. It sounds as if he is against using pit for slow dilitation (i.e. ” provided no ill-advised measures for stimulation …..are undertaken”) and is recommending using it for arrest only. This is pretty different from something like the Dublin Protocol.

    • Amy Tuteur, MD

      That’s correct!

      When he refers to the ill advised use of pitocin he’s referring to using it when you have radiographic evidence that the pelvis is too small to accommodate the presenting part.

      • fiftyfifty1

        Still confused. You are saying the “ill advised” refers to use of pit when there is evidence the presenting part doesn’t fit. That is black and white.

        But what matters are the grey zones: What about for extremely protracted labor? What about for a very irregular contraction pattern with extremely slow dilitation during what should be active labor? What about for a protracted labor with rupture of membranes. All these situations seem like good times to try pit rather than just be patient. Just how long does one sit on ones hands? The Dublin Protocol says not at all. What does Friedman say?

        • Laura

          My concern with the Friedman idea of using pit very sparingly and rarely is that for the slow labors, especially the primips, the exhaustion factor weighs heavily into the picture. There is also the mental exhaustion of being in a hospital for possibly dozens of hours with limits on food intake and the earnest desire to have your baby and be done with the pregnancy. Curious as to how you used pit in your delivery days Dr. Amy…

          • http://www.antigonos.blogspot.com/ Antigonos CNM

            Dr. Friedman was writing before widespread use of epidurals [IIRC, at my hospital, in 1972, they had not yet begun to be used, although quite a few caudals were done]. The exhaustion factor is definitely reduced with epidural; many women react to them by falling asleep — some for the first time in days.

          • Young CC Prof

            While I was pregnant, quite a few women told me that about their epidural births. “Labor was going on and on and I was so tired, then I got my epidural and had a wonderful nap, then I woke up and it was time to push so I pushed out the baby. Epidurals are awesome.”

          • ngozi

            I have heard mostly good stories about epidurals, but I have heard a few bad ones. I was at the doctor’s office and two ladies were talking about how their backs “lock up” since they have had their epidurals. One lady said that she once dropped her baby because of it (fortunately he fell on the bed).

          • Elizabeth A

            I have all the stories about how epidural enabled a wonderful nap too. It’s awesome.

            My epidural did leave my spine feeling bruised – the feeling took nearly a year to go away – but it was more then worth it.

          • Young CC Prof

            Some people do get injuries from the epidural, but also some women have back pain as a result of the pregnancy that they mistakenly attribute to the epidural.

          • ngozi

            Hhhmmm, good point.

          • Anj Fabian

            The problem with those stories is that there are multiple ways for injury or problems to occur:

            Back and joint problems are not uncommon during pregnancy and those problems are not going to spontaneously resolve immediately after birth.

            Giving birth can also cause back or hip problems.

            So pinning the blame on the epidural is convenient, but the accuracy is questionable.

          • batmom

            I’d be skeptical (as others have said) of the causal inference there. I had an epidural, but the back, hip, and piriformis pain I’ve had since having the baby is almost certainly attributed to the lack of core strength post-partum (as when I do PT and work my core, the pain decreases.) My doctor suspects I injured my back while pushing! (Things NCB people never mentioned: that you could tear your own back apart in labor. Yikes.)

          • Laura

            I agree! The augmented labors with epidurals are the only way to go. I remember telling my nurse after my epidural was placed, “Turn up the pit!” I promptly fell asleep and then about an hour or so later was holding my baby in my arms. A beautiful birth indeed!

          • Amy Tuteur, MD

            I didn’t cover it in my post, but it sounds like what you are talking about is prolonged latent phase. That’s another dysfunctional labor pattern and Friedman recommends that it not be allowed to extend indefinitely. Once it has lasted beyond 20 hours, a woman should either be given morphine for sedation so she can rest and then pitocin to start labor if it doesn’t restart on its own when she awakens.

            There’s zero benefit to irregular, inefficient contractions that last four days and leave a mother exhausted before real labor actually begins.

        • Dr Kitty

          I’ve said before- my undergraduate training was in Dublin, in a hospital that used (surprise surprise) the Dublin protocol for active management. Women were informed and able to opt out, although most LIKED the fact that you were guaranteed to have a baby in your arms one way or another 14 hrs after you arrived at the hospital.