Emanuel A. Friedman M.D. introduced the Friedman Curve in 1955. In a recently submitted article written by Michigan lawyers Jesse M. Reiter and Emily G. Thomas, the authors and stalwarts of the Birth Trauma Litigation Group write that the gold standard for assessing the normal and abnormal progress of labor was changed in 2014. The change by the American College of Obstetrics and Gynecology (ACOG) replaced Friedman’s curve with new labor standards.
The purpose of the Friedman Curve was to assess labor progression and to identify whether the mother had a “reduced likelihood of a safe vaginal delivery.” When there was an abnormal progress of labor, such as when neonatal morbidity and mortality were greatly increased, the analysis called on obstetricians to decide very quickly to rescue the unborn baby.
According to the Friedman papers, an “arrest of dilation” was diagnosed by documenting the lack of dilation progress in the active phase of labor. “Protracted active-phase” dilation was defined to be 1.2 cm per hour or 1.5 cm per hour where there was more than one fetus to be delivered. According to the paper submitted by attorneys Reiter and Thomas, two vaginal examinations done by the same individuals spaced two hours apart was good enough to make this diagnosis. If the cervix did not dilate according to the maximal slope on Friedman’s curve over two hours, the patient was diagnosed with failure to progress/arrest of labor and delivered by Cesarean delivery. Cesarean delivery was then recommended to avoid neonatal death or catastrophic injury. Many studies over the 60 years showed that the research supported the Friedman Curve.
In a research paper written in 2010, it was concluded that mothers did not rapidly dilate starting at 3 cm as Dr. Friedman had found. The paper written by Dr. Zhang and others stated that active labor began at 6 cm. The majority of woman (95%) have been found to dilate 1 cm in less than 2 hours during an active labor. The average rate of dilation was 1.2 cm per hour.
In sum, what was considered “slow labor” by Dr. Friedman was now thought to be normal labor by Dr. Zhang. One of the problems the Zhang research revealed was that patients in the study received Pitocin to hasten labor, artificial rupture of membranes and epidurals were given for pain relief unlike the patients in the Friedman study. In addition, there was no consideration by Zhang’s research to consider whether the patient had undergone a Cesarean delivery in the past. Lastly, Zhang chose not to take into account other sources identified by Friedman as important such as exclusion of women in the study with advanced dilation on admission and the likely disparity in dilation rates among women admitted at different times in the labor process.
The ACOG changes lead to lower Cesarean rates. The Zhang research and ACOG have taken the position that the Friedman curve was no longer valid and is now outdated. ACOG and the Zhang research reached the decision that women were being incorrectly diagnosed with failure to dilate in labor, when they might be experiencing normal progressive labor.
As a result, ACOG published the Obstetric Care Consensus, “Safe Prevention of the Primary Cesarean Section Delivery,” in March 2014, which recommended new guidelines for handling labor. The ACOG publication defined “arrest of labor” in the first stage and replaced the Friedman Curve with its 60 years of supporting evidence.
“Cesarean delivery for active phase arrest in the first stage of labor should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who failed to progress despite 4 hours of adequate uterine activity (>200 Montevideo units), or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.”
Clearly, the ACOG changes were designed to decrease the rate of C-section for “failure to progress.” The committee members at ACOG noted that the “slow but progressive labor in the first stage of labor should not be an indication for Cesarean delivery.”
Dr. Friedman and his colleague Dr. Kohn responded critically to the new guidelines. “The guidelines are not, in today’s popular terms, evidence-based. On the contrary, there is no compelling objective evidence whatsoever to support these new recommendations.”
The Friedman Curve had long been the standard and the most valuable of means in which to clinically evaluate individual women predicting the outcome of labor.
Lawyers who specialize in birth trauma litigation have from the beginning always been challenged by new and different ACOG publications that in many instances have made it more dangerous for women in childbirth and for the unborn. Although these challenges remain daunting, lawyers in this field have tirelessly worked to overcome them successfully protecting the rights of clients and children injured by negligence of physicians before and during childbirth.
With great gratitude to attorneys Jesse Reiter and Emily Thomas for their extremely well-researched and informative article on the Friedman Curve and the new challenges that continue to be promoted by those opposed to the logical protection of the unborn.
Kreisman Law Offices has been handling birth trauma injury cases, wrongful death cases, medical malpractice cases and hospital negligence cases for individuals and families who have been harmed, injured or died as a result of the carelessness or negligence of a medical provider for more than 40 years in and around Chicago, Cook County and its surrounding areas, including Aurora, Franklin Park, Frankfurt, Flossmoor, Chicago (Englewood, North Lawndale, Hegewisch, East Side, Jackson Park, Garfield Park), River Grove, Kenilworth, Prospect Heights, Arlington Heights, Naperville and Deerfield, Ill.
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