PRIMIGRAVID LABOR - A GRAPHICOSTATISTICAL ANALYSIS
PRIMIGRAVID LABOR - A GRAPHICOSTATISTICAL ANALYSIS
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DOI：
10.1097/00006250-195512000-00001
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发表时间：
1955-01-01
影响因子：
7.2
通讯作者：
FRIEDMAN, EA
中科院分区：
文献类型：
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作者：
FRIEDMAN, EA
这篇文章描述了第一产程的图形描述，其中宫颈扩张与从规则宫缩开始所经历的时间作图。研究人群包括来自纽约市哥伦比亚长老会医学中心斯隆妇女医院的500名有详细、准确和完整记录的早孕产妇。直肠或阴道检查估计的宫颈扩张被绘制在正方形格纹纸的纵坐标和横坐标上的小时数，产生由两个主要阶段组成的不对称S形曲线，潜伏期（从分娩开始到扩张速率开始变化的点）和活跃期（从该点到完全扩张）。潜伏期和活动期的计算平均值分别为8.6和4.9小时，“统计学最大值”（平均值加两个标准差）分别为20.6和11.7小时。活动期由三个细分组成，其中最重要的是最大斜率，平均每小时3厘米，正常最小值（第95百分位数）为每小时1.2厘米。与潜伏期和活动期延长最常见的相关性分别是子宫颈未成熟和胎儿骨盆不称;过量的镇静或镇痛药物似乎延长了这两个阶段，但潜伏期对效果特别敏感。在活动期明确建立后给予骶麻，似乎不会改变正常分娩。胎膜破裂对产程的影响取决于时间;潜伏期的剖宫产导致产程延长（11.5小时对10.5小时，“临界意义”）。弗里德曼可能并没有真正发现任何关于分娩过程的新东西，因为助产士和产科医生无疑早就意识到宫颈扩张开始缓慢，然后在某个时候进行得更快。弗里德曼所做的是以一种有助于量化从而标准化的方式定义劳动。它将在几个独立但相关的方面产生巨大的影响。首先，它引入了描述性且易于理解的术语，而不是反映假定机制的术语（“原发性和继发性子宫惯性”）。其次，它定义了劳动的组成部分，并促进了每个阶段规范数据的精确数学推导。第三，它使人们认识到，不同阶段的畸变有不同的原因和差异很大的结果，弗里德曼在接下来的一二十年里发表了一系列报告，其中大部分发表在《绿色杂志》上。最后，图解法被证明是一种极好的教学手段，因为它使人们一眼就能从字面上理解劳动过程。“弗里德曼曲线”或其变体将被纳入劳动室记录，一代又一代的美国医学生将发现它在揭开劳动神秘面纱方面的价值。在世界其他地方，特别是在英国及其英联邦，它将被称为“产程图”，起点可能会有所修改，但基本思想是弗里德曼在1955年的这篇文章中提出的。伊曼纽尔·弗里德曼在纽约出生、长大和接受教育。他从哥伦比亚大学获得了医学博士（1951年）和理学博士（1959年）学位，同时也是那里的一名内务官员和初级教员。1963年，他被任命为芝加哥医学院的系主任，1969年搬到波士顿，在那里他是贝斯以色列医院的服务主任和哈佛医学院的教授。1990年退休到纽约市，他继续沉迷于歌剧的终身奉献，尤其是.
This article describes the graphic portrayal of the course of first-stage labor, in which cervical dilatation is plotted against elapsed time from the onset of regular contractions. The study population included 500 primigravid parturients with detailed, accurate, and complete records, from the Sloane Hospital for Women of Columbia-Presbyterian Medical Center in New York City. Cervical dilatation estimated on rectal or vaginal examination was plotted on the ordinate and hours of elapsed time on the abscissa of square-ruled graph paper, producing an asymmetric sigmoid curve composed of two main phases, latent (from labor onset to the point at which the rate of dilatation begins to change) and active (from that point until complete dilatation). The calculated means were 8.6 and 4.9 hours for latent and active phases, respectively, with the “statistical maximums”(mean plus two standard deviations) 20.6 and 11.7 hours. The active phase consisted of three subdivisions, of which the most important, the maximum slope, averaged 3 cm per hour, with a normal minimum (95th percentile) of 1.2 cm per hour. The most common associations with prolongation of the latent and active phases were an unripe cervix and fetopelvic disproportion, respectively; excessive doses of sedative or analgesic medication appeared to prolong both phases, but the latent phase was particularly sensitive to the effect. Caudal anesthesia, administered after the active phase is clearly established, did not seem to alter normal labor. The effect of membrane rupture on the course of labor depended on timing; amniotomy during latent phase led to its lengthening (11.5 versus 10.5 hours,“borderline significance”). Friedman may not have really discovered anything new about the course of labor, for midwives and accoucheurs had undoubtedly long appreciated that cervical dilatation begins slowly and then at some point proceeds more rapidly. What Friedman did was define labor in a way that lent itself to quantitation and thus to standardization. It would prove enormously influential in several separate but related ways. First of all, it introduced terminology that was descriptive and understandable in place of that reflecting the presumed mechanism (“primary and secondary uterine inertia”). Second, it defined the components of labor and facilitated precise mathematical derivation of normative data for each phase. Third, it led to recognition that aberrations of different phases have different causes and widely varying prognoses, as Friedman would show in a series of reports over the next decade or two, most of them published in the Green Journal. Finally, the graphic approach proved to be a superb teaching device simply because it permits the course of labor to be comprehended literally at a glance. The “Friedman curve” or some variation thereof would be incorporated into labor room records, and generations of American medical students would find it invaluable in demystifying labor’s arcana. Elsewhere in the world, especially in Britain and its Commonwealth, it would be called the “partogram” and the starting point might be modified, but the basic idea was that put forth by Friedman in this 1955 article. Emmanuel Friedman was born, reared, and educated in New York. He took the MD (1951) and ScD (1959) degrees from Columbia University and was a house officer and junior faculty member there as well. In 1963 he was appointed department chair at Chicago Medical School, moving in 1969 to Boston, where he was chief of the service at Beth Israel Hospital and a professor in Harvard Medical School. Retiring in 1990 to New York City, he continues to indulge a lifelong devotion to opera, especially …