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UST FACULTY OF MEDICINE

2.12 Friedman’s Curve OBSTETRICS 1
& SURGERY SecC2021 Justine Val Jade B. Lacaba | October 25, 2018 SHIFTING 02 MODULE 12
ILTΣΒΤΦ ILTΣΒΤΦ ILTΣΒΤΦ

OUTLINE Phase Cervical Dilatation

Latent Phase <3cm - 4cm
I. Stages of Labor Active Phase >3cm - 4cm
II. Friedman’s Curve
A. Axes of the Friedman’s Curve
b) The Active Phase is further divided into 3 Phases
B. Cervical Dilatation
C. Fetal Descent
Phase Description
D. Integration Acceleration Phase
III. Examples of Friedman’s Curve Phase of Maximum Slope
Deceleration Phase
PURELY TRANSCRIBED FROM Dra. Lee’s Skills Lab on Friedman’s Curve
c) 3 Functional Divisions
I. STAGES OF LABOR
Division Description
Stage of Labor Description
Preparatory Division ● latent phase + acceleration phase
Stage 1 ○ cervical effacement and dilatation
clinical onset of labor ○ from onset of cervical effacement until full cervical dilatation
● corresponds to phase of maximum slope
Dilatational Division
○ characterized by rapid dilatation of the cervix
Stage 2 ○ fetal expulsion
fetal descent ○ from complete cervical dilatation to expulsion of fetus
● deceleration phase + 2nd stage
○ deceleration phase is 1 hour (lecture)
Pelvic Division
Stage 3 ○ 2nd stage is 2 hours in normal labor
○ placental expulsion ○ 2nd stage is prolonged when under epidural analgesia
delivery of placenta &
○ from expulsion of fetus until expulsion of the placenta
membranes

Stage 4 ○ period of monitoring

delivery of placenta & ○ monitor bleeding if it exceeds expected blood loss
membranes ○ 1st hour after delivery of the placenta

Check Biochemical Aspects & Clinical Aspects of Parturition for a complete description for each stage

II. FRIEDMAN’S CURVE

A. AXES OF THE FRIEDMAN’S CURVE

C. FETAL DESCENT
AXIS Denotes
Y-axis on Left-hand side denotes cervical dilatation in cm STATIONS
Y-axis on Right-hand side denotes fetal descent in terms of fetal station shown as Y-axis at the right-hand side
X-axis denotes number of hours that the woman is in labor
a) Stations
B. CERVICAL DILATATION ○ refer to descent of fetal part in relation to the level of the ischial spines
○ shown in units of centimeters (eg -3 = 3cm above ischial spines)
CURVE FOR CERVICAL DILATATION ○ at +5, the lowest part is at the level of the pelvic floor = pelvic division

Sign Meaning
a) progresses as uterine contraction becomes more frequent
Negative fetal part above the ischial spines
b) plotted at 2cm → 4cm → 8cm → 10cm Positive fetal part below the ischial spines
○plotted against the number of hours that the woman is in labor

c) when plotted, shows a SIGMOIDAL CURVE b) Station 0

○ the lowermost portion of the head
X-AXIS FOR CERVICAL DILATATION ○ is at the level of the ischial spines
○ means that the head is engaged
a) Cervical Dilatation in the First Stage of Labor
○ was divided into Latent & Active Phase c) Engagement
○ demarcation line occurs at 3cm - 4 cm ○ occurs when biparietal diameter
○ when the cervix is 3 cm, the woman is in the Active Phase ○ passes through the pelvic inlet
3 – 6cm is a new magic number in Williams 25th and will be taken up
in the module on Clinical Aspects of Parturition

LACABA, Justine Val Jade B.

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CURVE FOR FETAL DESCENT

a) progresses as cervix continues to dilate EXAMPLE

b) stations of fetal descent plotted against number of hours in labor 12nn, cervical dilatation at 3cm, MVU = 210, G3P2
When will the patient undergo delivery?
d) when plotted, shows a HYPERBOLIC CURVE
ANALYSIS
○ since the Px is multi (G3P2) in active phase (>3cm)
FETAL DESCENT ○ with good uterine contractions (MVU = 210)
○ the progression at active phase is expected to be 1.5cm/hour
a) fetal descent starts at the phase of maximum slope ANSWER
b) start of descent starts at cervical dilatation = 7cm – 8cm ● Determine when the patient will reach 10cm = delivery
c) At 8cm, there should be progression of cervical dilatation & fetal descent ○ The patient will reach 10cm after 4.7 hours, around 4:42pm

D. INTEGRATION
FETAL DESCENT

a) Starting from the phase of maximum slope

○ fetal descent is expected to be:

Parity Fetal Descent

Nullipara (Primigravida) 1cm/Hour
Multipara 2cm/Hour

b) fetal descent follows progress in cervical dilatation

○ again, fetal descent starts at 7-8cm

c) thus, proper sequence should be:

○ good uterine contractions → progress in dilatation → fetal descent

SECOND STAGE OF LABOR

LATENT PHASE Parity Length of Second Stage

Nullipara (Primigravida) average of 50 minutes
a) do not expect progress in dilatation, only small progress occurs Multipara average of 20 minutes

b) Length of Latent Phase

a) fetus should be expelled within 50 minutes after full cervical dilatation
○ if it exceeds expected length, there is prolonged latent phase
b) in multiparas, this is much faster: within 20 minutes
Parity Length of Latent Phase
Nullipara (Primigravida) should not last more than 20 hours
IMPORTANCE OF FRIEDMAN’S CURVE
Multipara should not last more than 14 hours
a) plotted in order to detect abnormalities during labor

ACTIVE PHASE b) if the cervix does not dilate despite good uterine contractions,
○ evaluate the patient according to: Pelvis, Passages, Power
a) Acceleration Phase ○ assess engagement: capability of pelvic inlet has not yet been tested
○ starts when the cervix is dilated = 3cm – 4cm ○ assess malposition: occiput posterior? mentum posterior?
○ Williams 25th: dilatation of 3-5cm in presence of uterine contractions

Parity Progress in Dilatation during Active Phase

Nullipara (Primigravida) 1.2cm/hour
Multipara 1.5cm/hour

○ these values are only applicable if there is strong regular contractions

○ strong regular contractions → normal progressive cervical dilatation

MOTEVIDEO UNITS
this will be taken up more in depth in future modules

a) Motevideo Units (MVU) used to describe good uterine contractions

b) MVU > 180 is considered adequate for normal labor progression
c) thus, at MVU > 180, expect normal progressive cervical dilatation

LACABA, Justine Val Jade B.

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III. EXAMPLES OF FRIEDMAN’S CURVE

Time Findings

SYMBOLS USED IN FRIEDMAN’S CURVE ○ painful uterine contractions since 4hrs ago
in obstetrics, the following symbols are uniformly used ○ with bloody mucoid discharge
○ PPE: BP-110/70 FH-43cm FHT 140bpm
● represents cervical dilatation LM1 breech, LM2 FBR, LM3 cephalic
★ represents station, usually abbrevated as ST ○ IE: Cx-3cm dilated, 40% effaced, (+) BOW, ST 0, ROA

After 4 Hours ○ Cx 5cm, 80% effaced, Station 0, ROA

CASE 0 After 4 Hours ○ Cx fully dilated, OA, Station +1

JS, 25 year old pimigravif 38-39 weeks

CASE 2

AM 28 y/o G3P2 (2002) 38-39 weeks

picture was not obtained

Time Findings

○ watery vaginal discharge w/ painful uterine contractions

○ since 3 hours ago
○ PPE: BP-120/70 FH-33cm
LM1 breech, LM2 FBL, LM3 cephalic
○ Speculum: (+) pooling of clear amniotic fluid
○ IE: Cx 2cm dilated, 70% effaced, (-) BOW cephalic ST -2

After 5 hours ○ Cx 6cm, 80% effaced, Station -1 LOA

Time Findings
After 2 hours ○ Cx 6cm OA station -1
○ Hypogastric painst radiating to lumbosacral area
○ VS: BP - 100/60 PR - 80/min RR - 20/min Three hours later ○ Cx 9cm, fully effaced, station 0
○ Abdomen: FH – 32cm FHT – 140bpm
One hour after ○ Cx fully dilated, fully effaced station +1
LM1 – breech, LM2 – FBL, LM3 – cephalic
○ Uterine contractions: 5-6min 40-50sec, moderate
○ IE: Cervix-3cm, 80% effaced, LOT (+) BOW, Station -2 CASE 3
○ complained of watery vaginal discharge
○ UC: 3-4min 50-60sec, moderate TL 32 y/o G6P5 (5005) 29-40 weeks
2 hours after
○ Speculum exam: pooling of clear amniotic fluid
○ IE: Cervix-5cm, 90% effaced, LOA, (-) BOW, Station -2
2 hours after ○ IE: Cervix-8cm, fully effaced, LOA, (-) BOW, Station 0

○ complined of having urge to defecate

1.5 hours later
○ IE: Cervix-fully dilated, fully effaced, OA, (-) BOW, ST +2

○ delivered a live baby girl

30 mins after
○ BW – 3.0kg, AS – 8.9

CASE 1

GS 20 y/o, Primi 39-40 wks Time Findings

○ bloody mucoid discharge

○ accompanied by painful uterine contractions
○ PPE: BP-150/80, FH-37cm
LM1 breech, LM2 FBR, LM3 cephalic, FHT 130bpm
○ IE: Cx 2cm dilated, 70% effaced, (+) BOW cephalic ST 0

After 3 hours Cx 4cm, 80% effaced, Station 0, ROA

After 2 hours had watery vaginal discharge, Cx 7cm, ROA, Station 0
After 2 hours Cx 8cm, 80% effaced, (-) BOW, ROA, Station 0
After 2 hours On IE Cx 8cm fully effaced, (-) BOW, ROA, Station 0
After 1 hour Cx 8cm fully effaced, (-) BOW, ROA, Station 0

LACABA, Justine Val Jade B.

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CASE 4

AM 20 y/o primi 40-41 weeks

Time Findings

○ painful uterine contractions since 4 hours ago

○ with bloody mucoid discharge
○ PPE: BP-130/80 FH-37cm
LM1 breech, LM2 FBR, LM3 cephalic, FHT 140bpm
○ IE: Cx – 3cm dilated, 70a% effaced,
(+) BOW, cephalic, Station -1

○ had watery vaginal discharge

After 4 hours ○ with UC every 3-4 mins 50 sec, moderate
○ IE: Cx 4cm, 80% effaced, Station -1, ROA
After 4 hours Cx 6cm ROA, Station 0
After 1 hour Cx 7cm ROA, Station 0

END

LACABA, Justine Val Jade B.

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