Rethinking Normal Labor Could Reduce the C-section Rate

C-Section for Breech Presentation

The second I hit save on the manuscript for The Pregnancy Companion, the information began to evolve. Medical and scientific breakthroughs happen on an hourly basis. In additi0n to serving as a community for our readers, this blog serves as my way to help keep the book’s information fresh. This blog post updates the information on pages 167-169 in The Pregnancy Companion book.

Last year I discussed ways that you as a patient can help reduce your c-section risk.  A study has recently come out that will hopefully give providers another tool to help safely reduce the c-section rate.

50 years ago, an OB/GYN by the name of Friedman did research on ‘normal labor’ and published his ‘Friedman curve.’  I reference this in the book multiple times as it has been the gold standard for defining normal labor for the last 50 years. The Friedman curve is memorized by every doctor and nurse as they pass through training. His data states that women should dilate 1 cm an hour after 4 cm. If that doesn’t happen, it is considered dysfunctional labor. If no cervical change occurs in 2 hours, then a C-section should be considered. This is a summary, but you get the gist. I have always felt these rules to be stringent. It didn’t take me long in the real world of practice to realize that most women’s bodies do not work that way. Maybe their bodies didn’t read the text book. I would often allow women extra time to dilate and often they did.

Zhang et al recently published an article in Obstetrics & Gynecology (Vol. 116, NO. 6 Dec 2010 p. 1281- 1287) that has blown away Friedman’s work.  He looked at labor curves of 62,000 women from 2005-2007. Guess what? Women today do not labor the same as they did 50 years ago.

Currently 30% of pregnant women are obese, the average first mother is older and the average birth weight has steadily increased.

New Flash: Fat Old Women Do Not Labor the Same as Skinny Teenagers!

Wow. We doctors sure are smart.

The key study findings were that current normal labors are much longer than they were 50 years ago:

1. Active labor likely begins at 6 cm instead of 4 cm.

The study showed that it was normal to take 6 hours to progress from 4 to 5 cm  and another 3 hours to progress from 5 cm to 6 cm.

After 6 cm, labor usually progresses at 1 cm an hour (not after 4 cm).

2. Average pushing time with an epidural for first baby is 1 hour, with some taking as long as 3.5 hours.

Average pushing time without epidural for first baby was 40 minutes, with some taking as long as 3 hours.

Average pushing time for second baby with epidural was 40 minutes, with some taking as long as 2 hours.

Average pushing time for second baby without epidural was 20 minutes, with some taking as long as 1 hour.

The C-section rate is too high in the US (approaching 30%).  This study gives providers the science to back up what many of us have long suspected, that women today dilate slower.  As long as mom and baby are healthy, then it is OK to let them continue to labor without doing a preemptive C-section.

How long were you in labor and how long did you push with your baby?

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  1. 1


    this is a very timely article for me. just today i had my 17 week appointment. my OB is referring me to a high risk doctor for the 20 week ultrasound for no other complication than my weight. i’m obese, but have actually been losing weight throughout the pregnancy (non-intentional, but not a problem).

    she then proceeded to tell me that obese women had a 50% chance of a c-section.

    i’m 28. this is my first child. (and my husband and i are wanting at least 2.) i know that, basically, if i have a c-section with this one, i’m signing off on a c-section for all the others… and i don’t want to do that. i want to have a vaginal birth… and feel like i should be given a shot at it.

    she did cite the very study you mentioned… and also said that statistically, that an obese woman’s uterus doesn’t progress like a non-obese woman’s does. i asked her if OBs were more “patient” with non-obese women to progress more slowly than obese ones– seeing as they already know the statistics “against” them, it would seem like they would just “cut to the chase” so to speak. she said no… but honestly, it makes me wonder.

    curious to know… are the statistics really that high? i almost feel like she wanted me to resign to a c-section… and i haven’t even made it to the half-way mark… :/

  2. 3


    I also wonder if the rise in inductions over the years contributes to the C-section rate. I was induced @37 weeks, closed cervix, and fortunately my OB was very patient and let me labor slowly, (20 hours) and pushing (3 hours). This was my first at age 30, and I opted for the epidural. Pitocin is a wicked liquid.

    • 4


      Yes, I think the induction rate has definitely contributed to the rising CD rate. I think this study will help reduce the CD rate with induced labors as well.

  3. 5

    Tiffany says

    Very interesting! I had my first child at age 26 & my 4th child at age 32.

    Baby 1 – 13 hrs of active labor – pushed 1hr, 8 min
    Baby 2 – 7.5 hrs of active labor – pushed 4 minutes
    Baby 3 – 7.5 hrs of active labor – pushed 4 minutes
    Baby 4 – 3 hrs, 40 minutes of active labor – pushed 5 minutes

    I had an epidural with each baby & was given pitocin on #2&3 to help move things along. I was induced with #4.

  4. 6

    Alicia says

    My first baby I was in active labor for 16 hours and pushed for 2.5 hours (He was born on my 34th birthday, 9 days overdue). My second baby I was in active labor for 19 hours and ended up having a c-section. (Also 9 days overdue) She was stuck in a transverse position and not turning or progressing. When she was delivered they discovered she had the cord wrapped twice around her neck. With both of our babies we were trying to have as natural labor and deliveries as possible. While it was somewhat disappointing to have had a c-section with my second, I am just so grateful to live in a day and age where medical intervention was able to safely deliver my beautiful baby girl into this world, happy and healthy.

  5. 7

    T. says

    I have always thought that the high number of C Section in the US depended on the rather sue-merry US behaviour o.o

    (In my country, Italy, it depends on the fact that women WANT a C-Section, and woe to the hospital who tries to deny them :P Same with epidural)

    I would like to know if there is a statistic showing the average rate of c-sections of doctors who have never been sued VS doctors who have.

    PS: I think that the current sue-merry approach of medicine of many US citizens is nothing short of madness and force doctors to do things they wouldn’t do, usually. Meaning: it is not the doc fault, it is the crazy patient who doesn’t get that, quoting Forrest Gump “Shit Happens”, sometimes in spite, not because, what docs do.

  6. 8

    Ashley says

    I was 22 when my first child was born. The delivery was perfect. I was induced around 8am. I had pitocin and I was about 4cm before I even got to the hospital. My blood pressure was going up a little so I decided to get the epidural. I knew that it would help my blood pressure go down. The nurse I had recommanded me to do it. So, I did. Then Doctor Rupe came in and broke my water. She said it would be a few hours. About 30 mins. later I felt alot of pressure and I asked my husband and mother to look down there. Sure enough I was crowning. My husband ran out of the room. I was laughing at them. They where so freaken out. I was in a hospital so I knew everything would be ok. I just kept laughing at them. The nurse came in and said that she didn’t think it was time yet. She checled me and ran out the room. lol Doctor Rupe came in about 15 mins later. She was in a hurry to get her scrubs on. I was still laughing at all of them. Everyone was telling to laughing. Every time I laughed she would come out a little more. lol I pushed once and there she was. It was perfect. My doctor said she has never been laughed at before.

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