Birth Partner | For Everyone at the Birth

Source: *The Birth Partner* (5th ed.) — Penny Simkin with Katie Rohs

The Take-Charge Routine

Use this when the laboring person has lost their rhythm and cannot recover it on their own — most commonly in transition or during a particularly difficult stretch of active labor.

The Take-Charge Routine is not aggressive. It is confident, focused, and anchoring.

**Step by step:**

1. **Get face to face.** Crouch or kneel to get at their eye level. Do not talk down to them.

2. **Get their eyes open.** If their eyes are closed and they are spiraling, a firm but calm "Open your eyes. Look at me." can re-anchor them to the present moment.

3. **Anchor physically.** Hold their hands, or place your hands firmly on their shoulders or cheeks. Physical connection is grounding.

4. **Lead the breathing.** Breathe loudly and deliberately, making each breath visible and audible. Do not tell them what to do — just model it. "Breathe with me. In... and out... in... and out."

5. **One contraction at a time.** Do not talk about how many more contractions are left, how close to full dilation they are, or what comes next. "Right here. Just this one. Stay with me."

6. **Stay with them for the whole contraction.** Do not look away, check your phone, or have a side conversation with a nurse during a contraction when the laboring person needs you.

7. **Between contractions:** Brief words of affirmation. "You did it. One more gone. You're doing this."

8. **Repeat.** Stay in this mode until the rhythm is re-established.

On-the-Spot Coaching (When There Was No Preparation)

Sometimes a birth partner arrives with little or no preparation — a partner who was deployed, a family member called in unexpectedly, a doula arriving to a person already in advanced labor without any classes. This is what to do:

**Establish rhythm first.** Do not try to explain anything. Just get alongside them physically and start modeling breathing. Breathe loudly. Make it clear you are doing it with them.

**Use slow breathing first.** "Breathe with me. Slow. In... out... in... out." Use your own breath as the model.

**If slow breathing doesn't work, shift to light breathing.** Quicker, shallower breaths at the chest level. Still rhythmic. Still led by you.

**Hold their hands or their gaze.** Any anchor helps.

**Say fewer words, not more.** Information does not help during a contraction. Presence and rhythm help.

Very Rapid Labor

Sometimes labor is short, intense, and moving faster than expected. Contractions arrive strong with little warning. The laboring person barely finishes one before the next begins.

**What this looks like:**

Contractions that feel immediate and overwhelming from the start
Labor that goes from "irregular" to "almost pushing" within a couple of hours
A laboring person who seems shocked at how intense things are, very quickly

**What to do:**

Take the Take-Charge Routine and use it immediately. Rapid labor is often harder than long labor because there is no gradual buildup to prepare the mind and body.

Call or go to the birth location immediately. Do not wait for the 4-1-1 rule if things are moving this fast.

**For positions:** Gravity-neutral positions can slow descent slightly if the pace is overwhelming: side-lying, hands-and-knees, semiprone. Do not use upright or squatting positions if trying to slow things down.

If pushing begins before reaching the hospital, implement the emergency delivery protocol below.

Emergency Delivery (When Birth Happens Before Help Arrives)

Rare, but possible with very rapid labor, especially for subsequent births. Be calm. The body knows what to do.

**Step by step:**

1. **Call 911.** If you have not already, call while delivery is beginning. Keep the dispatcher on the line.

2. **Encourage panting.** "Pant for me. Like a dog. Don't push." This slows the birth and protects the perineum. The chin should be up, not tucked to the chest.

3. **Prepare the catch zone.** Get towels, blankets, or clothing under the laboring person. Position can be whatever is most comfortable — lying back, hands and knees, standing.

4. **Check membranes at the head.** If a glistening sac is visible over the baby's head and has not broken, it will usually tear on its own. If it doesn't, use a clean finger to break it away from the face so the baby can breathe.

5. **Catch, do not pull.** Support the baby's head as it emerges. Do not pull. Guide the baby gently as the body follows.

6. **Place on the chest immediately.** Put the baby directly on the birthing person's bare chest or belly, face down if possible. Skin-to-skin begins warmth and bonding immediately.

7. **Dry and stimulate.** Rub the baby briskly with a towel or whatever clean fabric is available. This dries them, warms them, and stimulates breathing.

8. **Watch for breathing.** Most babies breathe and cry within 30 seconds. If the baby is not breathing or crying in 2 minutes, begin infant CPR: 30 chest compressions (two fingers on the breastbone, just below the nipple line, compress about 1.5 inches) followed by 2 gentle rescue breaths covering both nose and mouth.

9. **Do not cut the cord.** Leave the umbilical cord intact. It does not need to be cut until help arrives. If it is tangled around the baby's neck (loose loop), slip it over the head. If it is tight, call for instruction from the dispatcher.

10. **Deliver the placenta.** The placenta will deliver on its own, usually within 15 to 30 minutes. After delivery, check the uterus: feel below the belly button for a firm, grapefruit-sized mass. If the uterus feels soft, massage it firmly with circular motion to help it contract.

11. **Keep everyone warm.** Blankets, clothing, skin-to-skin. Prevent hypothermia.

Slow-to-Start Labor

Labor begins but contractions are irregular, infrequent, and not progressing. This is common and frustrating, particularly at night.

**What helps:**

During the day:

Walk — every hour or two, 15 to 30 minutes at a brisk pace
Abdominal lifting: with a shawl or rebozo, lift the abdomen gently forward and upward during contractions. This can help a baby settle into a better position.
Use labor-stimulating positions: hands-and-knees, open knee-chest, walking up stairs sideways
Acupressure to SP-6 and Hoku point during contractions
Stay hydrated and eat regularly

At night:

Rest is more important than stimulating labor. Sleep on the left side.
Take a bath to relax. Warm (not hot) water.
Ask the caregiver about medications to help rest if contractions are preventing sleep

**Self-induction methods** (for overdue or slow-starting labor):

**Nipple stimulation:** Stimulate the nipple and areola manually or with a breast pump. This releases oxytocin and can start or strengthen contractions. Use for 15 to 20 minute periods, monitoring contraction pattern. Stop if contractions become too strong or too close together.
**Walking:** Sustained upright walking encourages the baby to descend and the cervix to dilate.
**Intercourse and orgasm:** Most effective self-induction method. Prostaglandins in semen soften the cervix. Orgasm releases oxytocin and causes uterine contractions.
**Castor oil:** A stimulant laxative. Causes intestinal spasms that can stimulate uterine contractions. Side effects: nausea, diarrhea, dehydration. Not universally recommended. Discuss with caregiver. Note: castor oil taken early in pregnancy was historically associated with meconium passage — current thinking is mixed but caution is warranted near the due date.
**Acupressure:** SP-6 and Hoku points, stimulated firmly during and between contractions
**Herbs:** Some herbs (blue cohosh, black cohosh, evening primrose oil) are used by traditional midwives. These have real physiological effects and should only be used under guidance from a midwife or naturopath who is experienced with them.

Slow Progress in Active Labor

Active labor is defined as dilation from roughly 6 cm forward. If dilation stops for 2 or more hours with adequate contractions, it is called arrested labor or dystocia.

**Causes:**

**Cephalopelvic disproportion (CPD):** The baby's head is too large, or more commonly, positioned in a way that creates a poor fit (occiput posterior, asynclitic/tilted, chin up). True CPD is less common than positional issues.
**Inadequate contractions:** Contractions that are not strong enough or frequent enough to dilate the cervix
**Exhaustion, dehydration, fear, or tension:** These factors measurably slow labor

**What to try before escalating to interventions:**

Position changes, particularly hands-and-knees or the standing lunge
Walking
Hydrotherapy (bath or shower)
Eating and drinking to restore energy and hydration
A rest period: a short-acting narcotic may allow 1 to 2 hours of dozing, after which labor sometimes resumes more effectively
Acupressure
Emotional support — sometimes labor stalls when something is unresolved or the environment doesn't feel safe

**If conservative measures fail:** The caregiver will discuss amniotomy (AROM) and Pitocin augmentation. See the medical interventions file for detailed information. An epidural may allow rest that restarts labor.

**The birth partner's role in stalled labor:**

Stay emotionally present. Stalled labor is discouraging and exhausting.
Validate that it is genuinely hard. Do not minimize.
Gently suggest options (the code word, position changes, asking for a doula) without pressure.
Take care of yourself: eat, rest when the laboring person rests, so you have stamina for the second half.
If a doula is not present, this is the moment to consider calling one.

Back Labor

Back labor is the intense, persistent pain in the lower back that occurs when the baby is in a posterior position (occiput posterior: the baby's head is facing forward instead of toward the spine). The baby's skull presses on the laboring person's sacrum during contractions. Unlike front labor, back labor pain does not fully ease between contractions.

**Signs:**

Constant low back ache that intensifies dramatically with contractions
Very intense, difficult-to-manage contractions
Slow progress despite regular contractions
Baby's position confirmed by the caregiver

**What helps:**

Counterpressure on the sacrum — essential, not optional. Find the exact spot (it varies) and hold firm pressure throughout the contraction.
Double hip squeeze
Hands-and-knees position
Standing lunge with the foot on the side of the baby's back elevated
Abdominal lifting with a rebozo or shawl
Heat to the lower back (rice sock or heating pad)
Cold to the lower back alternated with heat
TENS unit on sacral electrode points
Position changes every 20 to 30 minutes to encourage the baby to rotate

Back labor often resolves when the baby rotates to an anterior position. The baby may rotate during labor, sometimes suddenly, with a noticeable shift in where and how contractions feel.

**Kneeling, pelvic rotation, and the posterior baby** (Source: *Active Birth* — Janet Balaskas): When the baby is posterior, kneeling on all-fours with slow rhythmic pelvic circles during contractions does two things at once. It gives immediate relief to the sacrum, taking the baby's skull off the bone, and it creates the conditions for the baby to rotate. Balaskas observed that spontaneous movement of the pelvis, rather than a prescribed exercise, is what allows the baby's head to find a new angle. The kneeling position also leans the trunk forward, so the uterus can contract downward rather than sideways against a reclining pelvis. If the laboring person is willing, spending several contractions in a row in kneeling all-fours with active pelvic movement is worth trying before concluding that rotation is not happening.

**A note on epidurals in back labor:** The instinct when back labor is relentless is to ask for an epidural. This is understandable. But Sears and others caution that an epidural in back labor carries a specific tradeoff: once the laboring person is confined to the bed without freedom to move, the chances of the baby rotating to a better position drop significantly. Hands-and-knees, the standing lunge, and pelvic rocking are the primary tools for rotation, and they all require movement. If the full range of position changes has been exhausted and the baby is still posterior without relief after many hours, the epidural becomes more reasonable. But if position changes have not been tried systematically, they should be tried first. Exhaust the mobility options before the epidural takes them away.

Breech Presentation

A baby is considered breech if the buttocks or feet are positioned to be born first instead of the head. This affects approximately 3 to 4 percent of full-term pregnancies.

**External cephalic version (ECV):** A procedure performed at 36 to 37 weeks where the caregiver applies firm pressure to the abdomen to manually turn the baby to a head-down position. Success rate: approximately 50 to 60 percent. Performed in the hospital with monitoring and an IV in place in case emergency cesarean is needed.

**How the birth partner helps with ECV:**

Be present for support
The laboring person receives a medication to relax the uterus before the procedure
An epidural or spinal may be offered to reduce discomfort during the version
Monitor fetal heart rate before and after

**Natural techniques to encourage turning (before version or as adjuncts):**

**Breech-tilt position:** Lie with hips elevated on cushions, knees bent, feet flat. 15 to 20 minutes, 3 times daily. Some evidence supports this.
**Hands-and-knees rocking:** May encourage baby to shift position
**Swimming:** Buoyancy may allow more fetal movement
**Sound:** Placing headphones or music low on the abdomen below the current head position — theoretically encouraging the baby to turn toward the sound. Not well-studied but harmless.
**Acupuncture/moxibustion:** Burning a moxa stick at Bladder 67 (outside tip of the pinky toe) is used in traditional Chinese medicine. Research shows modest benefit. Must be done by a trained practitioner.

If the baby is breech and does not turn, cesarean delivery is most commonly recommended. Vaginal breech birth is possible in some circumstances with a trained and experienced provider.

Laboring Through Previous Trauma

Some birthing people have a history of sexual abuse or previous traumatic birth experiences. Labor, with its loss of control, physical vulnerability, and focus on intimate body parts, can trigger trauma responses.

**Signs to watch for:**

Extreme panic or dissociation out of proportion to where they are in labor
Strong resistance to touch, even from a trusted person
Difficulty staying present during contractions
Specific triggers (a particular procedure, a particular position, certain words)

**What helps:**

Knowing the triggers in advance and communicating them to the care team. Include in the birth plan.
Language of permission: "Is it okay if I...?" before any touch
The laboring person maintains as much control as possible over who touches them, what positions they use, and when exams happen
A doula trained in trauma-informed care is particularly valuable here
Simkin and Klaus's book *When Survivors Give Birth* is the primary resource for deeper guidance

**The birth partner's role:** Stay attuned to what is happening emotionally, not just physically. If the laboring person is struggling in a way that seems different from the physical experience of labor, be curious and gentle. Ask if they need you closer or further. Ask if there is something you can do or stop doing. Do not problem-solve; be present.