Comfort Measures for Labor

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

Pain vs. Suffering: The Foundation

Labor pain and suffering are not the same thing.

**Pain** is the physical sensation of contractions. It is real. It is intense. For most people, it is unlike anything they have felt before.

**Suffering** is the emotional and psychological experience layered on top of pain — fear, loss of control, isolation, helplessness, confusion. Suffering amplifies pain dramatically.

The goal of comfort measures is not to eliminate pain. It is to prevent suffering from layering on top. When a laboring person feels safe, informed, supported, and in control of their responses, their experience of pain is genuinely different — not easier in the sense of less intense, but manageable, meaningful, and survivable.

Knowledge replaces fear. Presence replaces isolation. Rhythm replaces chaos.

The Three Rs: The Core Framework

Everything in labor comfort comes back to three words: **Relaxation, Rhythm, Ritual.**

**Relaxation:** When the body is tense, pain is amplified. When the body can release tension between and even during contractions, the experience shifts. The birth partner's job is to help the laboring person release, not tighten.

**Rhythm:** Whether it is a breath pattern, a sound, a rocking motion, or a mantra, laboring people who find a rhythm and stay in it cope far better than those who don't. Rhythm is the single most reliable predictor of coping. If you see rhythm, protect it. If you don't see it, help create one.

**Ritual:** A ritual is a contraction-specific pattern that gets repeated the same way every time. It might be: close eyes, take one slow breath, moan on the exhale, grip your hand, open eyes. Whatever works. The ritual creates predictability and control. When the birth partner notices what the ritual is, they can participate in it and reinforce it — not disrupt it.

If the laboring person breaks their rhythm or ritual and can't get it back, that is the signal to step in more actively. See Take-Charge Routine.

Relaxation Techniques

Passive Relaxation

Between contractions, the goal is to go completely limp: muscles of the face, shoulders, hands, hips, legs. The birth partner can do a brief body scan between contractions, touching a spot that looks tense (a shoulder, a fist) and saying quietly, "Let go right here." Release tension area by area.

The "floating" technique: imagine the body floating in warm water. With each exhale, sink a little deeper.

Attention Focusing

Giving the mind a specific focus during contractions reduces the experience of pain. Options:

• A visual focal point: a photograph, a candle, an object brought from home
• A repeated word or sound: "oooopen," "down," "yes"
• A visualization (see below)
• The birth partner's face or eyes

Visualization

A mental image the laboring person rehearses and returns to during contractions. Options to suggest before labor:

• A canoe floating on a lake, moved by the waves of each contraction
• Cycling up a long hill: the effort is real, the summit is coming
• The cervix opening like a flower
• The baby moving down with each wave

The visualization must be one the laboring person connects with. Ask in advance. Do not impose one during labor.

Rhythmic Breathing

Slow Breathing

Used in early to active labor. 5 to 12 breaths per minute. In through the nose, out through the mouth or nose. Long, slow exhales. The birth partner can breathe with them, acting as a "conductor" — modeling the rhythm with their own breath or with a soft hand signal.

Light Breathing

For strong contractions in transition. 30 to 60 lighter breaths per minute, from the chest. This is not hyperventilation — the exhale should still be deliberate. It feels less like deep relaxation and more like controlled panting.

Conducting

The birth partner leads the breathing by modeling it, using their own breath, or using a hand gesture like a soft waving motion synchronized with inhales and exhales. This gives the laboring person something external to follow when concentration is difficult.

Moaning

Low, open-throated moaning during contractions is effective and physiologically appropriate. It keeps the throat and jaw relaxed (a tense jaw = a tense perineum), provides a rhythmic outlet, and is self-reinforcing. If the laboring person shifts to high, tight, panicked sounds, gently model a lower tone with your own voice.

Positions

Position changes every 30 to 45 minutes matter: they shift the angle of the baby relative to the pelvis and relieve pressure points. No single position is best for everyone or for every contraction.

Upright Positions

**Standing and leaning forward:** Lean against a wall, birth partner, or counter with arms above the head. Relieves back pressure, allows swaying.

**Walking:** Movement keeps the pelvis mobile, encourages descent. Even short laps of a hospital hallway help.

**Slow dancing:** The laboring person's arms around the birth partner's neck, swaying together. Intimate, rhythmic, and effective for early to active labor.

**Standing lunge:** One foot on a chair or birth ball, tilting the pelvis open. Particularly useful for back labor or when the baby is in a posterior position.

**Squatting:** Opens the pelvic outlet significantly. Supported squats using the birth partner, a squat bar, or a sling are easier to hold than unsupported squats. Very effective in pushing phase.

**Dangle:** The birth partner sits on a high surface (like a bed at maximum height or a chair). The laboring person stands in front and hangs from the birth partner's arms. Allows full weight-bearing squat without tiring the legs as quickly.

Hands-and-Knees

Takes weight off the spine, encourages a posterior baby to rotate, relieves back labor. Can be combined with a rocking motion or pelvic circles. The birth partner can apply counterpressure to the sacrum from this position.

Side-Lying

Restful, can be used with epidural. Place a pillow between the knees. Alternating sides every 30 to 45 minutes changes the angle for the baby. The peanut ball can be placed between the knees in this position to widen the pelvic outlet.

Sitting on a Commode or Toilet

The shape of the toilet seat relaxes the pelvic floor. Effective for stubborn early labor and for pushing. Cover with a chuck pad if needed. The birth partner can sit facing the laboring person on a stool and provide counterpressure.

Semiprone

Lying at a 45-degree angle on the left side with the right knee pulled up and supported. Opens the pelvis asymmetrically. Useful for rotating a posterior baby or slow descent.

Birth Ball

A 65 cm ball fits most people (smaller or larger based on height). Sit upright and sway, circle the hips, or lean over it from a kneeling position. The 500 lb weight rating matters — confirm before using. Birth ball positions are particularly good for active labor when the laboring person is not yet lying down.

Kneeling and Leaning Forward

Kneel on a mat or padded surface, leaning over a birth ball, chair, or the raised head of the bed. Takes weight off the back, frees the pelvis to move.

Hydrotherapy

Water is one of the most effective comfort measures available, and it is underused.

Bath vs. Shower

Both work. The bath is generally more relaxing, especially after 5 cm when labor is well established. The shower provides more focused stimulation — directing hot water at the lower back during contractions is very effective for back labor.

**Timing for the bath:** Research and clinical experience suggest the greatest pain-relieving effect is in the 1.5 to 2 hour window after getting in. After that, the relief is still real but less dramatic. Enter when the laboring person is asking for help — not too early.

**Water temperature:** At or below body temperature (98.6°F / 37°C). Warmer water may cause overheating and stress the baby.

**Monitoring:** A handheld waterproof Doppler allows the baby's heart rate to be checked without leaving the tub. Confirm the facility has one.

**Bag of waters:** Getting in the tub is safe even after the bag of waters has released. Scientific trials confirm this does not increase infection risk.

The Birth Pool or Tub

A deeper tub or dedicated birth pool allows full immersion of the abdomen. If water birth is planned, the birth happens in the tub. If not, the person labors in the tub and then exits for birth.

Heat and Cold

Heat

Applied to the lower back, abdomen, or perineum. Options:

• A rice sock (a tube sock filled with uncooked rice, microwaved 2 to 3 minutes) holds heat for about 20 minutes and molds to the body
• A heating pad with a moist towel between it and the skin
• Warm compresses (wet washcloths, microwaved briefly)

Heat relaxes muscles and relieves cramping. Particularly effective for back labor.

Cold

Applied to the face, neck, or lower back. Options:

• Cool washcloths on the forehead and neck
• Ice in a latex glove wrapped in a cloth (makes a flexible cold pack)
• A cold can of juice held against the lower back or neck
• Frozen packs in a pillowcase

Cold is often welcome in the later stages of labor when the body is radiating heat. Alternating heat and cold to the lower back can be very effective for back labor.

Transcutaneous Electrical Nerve Stimulation (TENS)

A TENS unit delivers small electrical pulses to the body through adhesive electrode pads, reducing pain signals before they reach the brain and stimulating endorphin production.

**Setup:** Four electrode pads are placed on the lower back — two on either side of the spine at the level of T10 to L1, and two lower at S2 to S4 (the sacral area). The laboring person holds the control unit and increases intensity during contractions.

**Key principles:**

• Start early, in prelabor or very early labor. TENS builds an endorphin bank over time; starting late reduces effectiveness.
• The person controls the intensity. They turn it up during contractions and down between them.
• Remove for the bath (TENS is not waterproof). Can be reapplied after.
• Many doulas have TENS units available to loan. They can also be rented or purchased (see resources for suppliers).

Acupressure

Two points are most useful for labor:

**Hoku Point (LI-4):** Located in the fleshy web between the thumb and index finger. Firm pressure during contractions. Research shows it reduces pain and may speed dilation.

**Spleen 6 (SP-6):** Located 4 finger-widths above the inner ankle bone (medial malleolus), just behind the tibia. Firm upward pressure. Also useful for stalled labor.

**Critical warning:** Do not use SP-6 before the due date. It is a labor-stimulating point and should not be used during pregnancy.

Apply firm, steady pressure to both points simultaneously during contractions. Release between. Can be combined with rhythmic breathing.

Massage

Three-Part Shoulder Massage

The laboring person sits or kneels leaning forward. The birth partner stands or kneels behind:

1. Broad strokes down from the neck across the shoulders

2. Circular kneading on the trapezius muscles (the meaty area between neck and shoulder)

3. Thumb pressure along the muscles on either side of the spine

Crisscross Back and Hip Massage

Place both hands flat on the lower back, fingers pointing toward the spine. With firm pressure, draw hands outward and downward in crossing arcs over the hips. Repeat in a steady rhythm during contractions.

Counterpressure

Firm, direct, steady pressure on the sacrum (the flat bone at the base of the spine). This is one of the most effective measures for back labor.

Apply with:

• Both hands, heels of the palms, pushing in and upward
• A tennis ball or massage ball rolled firmly over the area
• Rolling pressure using the birth partner's fist

Ask the laboring person where to press. The exact location matters and varies.

Double Hip Squeeze

Stand behind the laboring person (who is kneeling or on all fours). Place both hands over the upper buttocks, fingers pointing forward and downward. Squeeze inward and upward firmly during contractions. This temporarily widens the pelvic outlet, relieving the internal pressure that causes back labor.

Hand Massage ("Ice Pop")

The laboring person's hand is wrapped around an ice cube (or a cold juice can). The birth partner massages the hand, including the webbing, fingers, and palm, while the cold provides an additional sensory distraction.

Foot Massage (Three-Part)

1. Long strokes from toes to heel with firm pressure from both thumbs

2. Circular pressure across the arch of the foot

3. Gentle but firm kneading of the toes

Useful in early labor or when the laboring person is resting and wants touch but cannot handle massage on the back.

Music and Scent

Background music can anchor rhythm and mood. Prepare a playlist before labor with music that feels right. Aromatherapy (lavender, clary sage) can be calming for some people. Test for sensitivity before labor.

Peanut Ball

A peanut-shaped ball placed between the knees in a side-lying position. Keeps the pelvis open even when the laboring person is resting or has an epidural and cannot actively change position. The nursing staff can help position this. Hospitals increasingly have peanut balls available — ask.

Studies suggest peanut ball use with epidurals reduces labor duration and improves rotation of the baby.

The Jaw-Perineum Connection

Source: *Ina May's Guide to Childbirth* — Ina May Gaskin

There is a direct physiological relationship between the jaw and the pelvic floor. When the jaw is clenched or the throat is tight, the perineum holds tension as well. When the jaw relaxes and opens, the pelvic floor follows. This is not metaphor. It is anatomy.

Ina May Gaskin called this principle one of the most useful things she knew about labor. Three techniques follow from it directly.

**Lip-flapping (horse lips):** Relax the lips and exhale through them, letting them vibrate loosely. It sounds like what a horse does. It is nearly impossible to make this sound with a clenched jaw or a tight throat, which makes it a built-in check. If the laboring person can do horse lips, the jaw is open and the perineum is soft. If they cannot, guide them back to it. Demonstrated before labor, this becomes a natural fall-back technique when contractions escalate.

**Kissing:** Kissing on the mouth during or between contractions actively releases tension in the jaw, produces oxytocin (the hormone that drives contractions and builds love), and shifts the nervous system out of fight-or-flight. Gaskin documented multiple cases where labor that had stalled unlocked within minutes of genuine kissing. It requires a willing partner and a laboring person who is emotionally available for it, which is why it works better in some rooms than others. But when the emotional conditions are right, it is remarkably effective.

**Low-pitched sounds:** High-pitched, tight sounds in labor close the throat and tighten the perineum. Low-pitched sounds, moaning, humming, even roaring, keep the throat open and the jaw loose. If the laboring person is producing high, panicked sounds, guide them gently toward something lower. Model it with your own voice. A low "oooopen" or a deep moan during contractions is not loss of control. It is control directed inward rather than outward.

Language and Expectation

Source: *Ina May's Guide to Childbirth* — Ina May Gaskin

Gaskin observed that the word "contraction" frames the sensation as something closing and tightening, which encourages the body to respond in kind. She and the midwives at The Farm used the word "rush" instead. A rush is something that moves through, that peaks and passes, that has momentum. The change is subtle and does not matter for everyone, but for some laboring people it genuinely shifts the quality of the experience.

The broader principle is that language shapes expectation, and expectation shapes pain. A woman surrounded by stories of terrifying labor will approach birth with a prepared nervous system, primed for danger. A woman who has heard many stories of labor that were hard but manageable, even profound, will approach it differently. In the weeks before birth, actively seeking out accounts of positive, unmedicated, or chosen-to-be-medicated births, from people who speak about them with respect rather than war-story bravado, is a real form of preparation.

Laughing at Crowning

Source: *Ina May's Guide to Childbirth* — Ina May Gaskin

In multiple birth accounts from The Farm, Gaskin and her midwives observed that laughter during the crowning of the baby's head, at the moment of maximum stretch, caused the perineum to release rather than tear. The instinct for most people in that moment is to tighten, brace, and push as hard as possible. Laughter does the opposite. It relaxes the pelvic floor involuntarily and briefly.

This is not reliably reproducible as a technique, but it points to something useful: anything that produces genuine physical relaxation in the perineum during crowning, including a warm compress, slow controlled breathing, or gentle panting rather than hard pushing, serves the same underlying purpose.

Fear, Tension, and the Physiology of Stalled Labor

Source: *Ina May's Guide to Childbirth* — Ina May Gaskin

Fear does not just affect the mind during labor. It directly affects the body. When the laboring person is afraid, the body releases adrenaline and stress hormones that constrict blood vessels, direct blood away from the uterus, slow contractions, and cause the muscles of the pelvic floor to tighten. The result is a uterus working against resistance. Labor slows or stops.

This is sometimes framed as the "fear-tension-pain cycle." Fear creates tension, tension amplifies pain, pain creates more fear, and the cycle builds. The way to interrupt it is not to address the pain directly but to address the fear underneath it.

Gaskin documented cases where a midwife sat with a laboring woman and simply asked what she was afraid of. In several instances, the woman named something specific: a fear about the baby, a fear about the relationship, something unresolved between her and the person she was giving birth with. In some of those cases, having the conversation and finding resolution, not medical resolution, but emotional resolution, unlocked the labor within the hour.

The birth partner is in a unique position to have that conversation. Not as a therapist, but as someone who knows and loves the person in labor and can be trusted. If labor has stalled and nothing clinical explains it, ask. Sit quietly. Let the answer come without rushing toward a solution.

The PROGRESS Checklist

Source: *The Birth Book* — William and Martha Sears

A practical loop to run through when labor feels stuck or the birth partner is not sure what to do next. Work through each item before escalating to medical options.

**P — Position.** Has she changed positions in the last 30 to 45 minutes? Upright, squatting, hands-and-knees, side-lying. Movement changes the angle of the baby relative to the pelvis and shifts pressure points. Staying in one position, especially on the back, slows labor and increases pain.

**R — Relax and Release.** Check for held tension: face, shoulders, jaw, hands, inner thighs. Touch the tense spot lightly and say "let go right here." Release between contractions is what restores energy. Held tension between contractions compounds exhaustion.

**O — Output.** Has she urinated in the last hour? A full bladder causes painful spasms, crowds the baby's passage, and slows descent. Encourage a trip to the bathroom every hour. The toilet seat, as a bonus, is one of the best positions for labor and pushing.

**G — Gravity.** Is she upright? Sitting, kneeling, squatting, standing. Gravity assists contractions, encourages the baby to press on the cervix, and reduces the need for artificial augmentation. The uterus functions more efficiently when the baby's weight is working with the body, not against it.

**R — Rest.** Between contractions, the goal is complete release. If active labor has been going for many hours and exhaustion is real, a short-acting narcotic that allows 1 to 2 hours of dozing may restart labor more effectively than any other measure.

**E — Energy.** Check the calorie and fluid status. Dehydration slows contractions and depletes stamina. Small sips of water or a labor drink every few contractions. Light food in early labor. Honey provides a quick burst when energy is flagging deep in active labor.

**S — Submerge.** If things are getting rough and the facility allows it, immersion in water is one of the most effective comfort measures available. Labor in the tub, not just the shower. Research shows dilation can proceed at more than twice the speed in water compared to dry land, and measured pain perception drops significantly.

**S — Support.** Is she getting continuous emotional support? The evidence on this is unambiguous: a laboring person who has continuous skilled support labors shorter, needs fewer interventions, and rates the experience more positively. If the birth partner needs a break, call in a doula, a nurse, or a trusted friend, and make the handoff explicit rather than just stepping away.

Supported Squatting: What the Birth Partner Actually Does

Source: *The Birth Book* — William and Martha Sears

Squatting is the most effective second-stage position. Research shows that changing from lying down to a full squat can widen the pelvic outlet by 20 to 30 percent. In a supported squat, the birth partner makes this possible without tiring the laboring person's legs.

**Practice this before labor. It will feel awkward the first time, and labor is not the moment to figure it out together.**

**The standing supported squat:**

Stand behind the laboring person. Place your feet shoulder-width apart with bare feet for traction. When she goes into the squat, bend your knees slightly and let her weight ease back onto your thighs. Thread your arms far enough through her armpits so she can grip your forearms or hands if she wants to. Support her buttocks on your knees. Keep your back straight but lean slightly against a wall if you need support. Hold her through the entire contraction. After the contraction, help her ease forward into a kneeling position or back into sitting before you release.

**The toboggan squat:** Both of you sit against a wall, you behind her, her leaning back into you. This version is more sustainable for a long second stage.

**Timing:** Squatting is most useful in the second stage. It intensifies contractions by pushing the baby's head against the cervix, so it can be overwhelming in early active labor. Begin squatting when the cervix is fully dilated or when the urge to push arrives.

**If the laboring person cannot sustain a squat:** A squat bar on the birthing bed, the edge of a sturdy chair, or the toilet seat provide support without requiring the birth partner to hold the full weight. Sway side to side during the squat rather than staying still.

Why Upright Positions Work: The Physics

Source: *Active Birth* (revised ed.) — Janet Balaskas

The supine position, lying flat or reclined, became standard in Western obstetrics in the 17th century not because it was better for labor, but because it was easier for the physician. Before that, women gave birth upright in virtually every documented culture. Radiographic studies from the 1930s confirmed what midwives had always observed: squatting widens the pelvic outlet by up to 30 percent compared to the semireclining position. That number is not a small incremental improvement. It is the difference between a baby that fits and a baby that doesn't.

Three physical facts explain what happens when a laboring person lies down:

The sacrum and coccyx, which are designed to flex outward as the baby descends, are pinned against the bed. The pelvic outlet narrows. The baby must navigate a smaller space.

The weight of the uterus presses down on the aorta and vena cava, the major vessels that supply blood to and from the placenta. Reduced blood flow to the placenta can cause fetal distress.

The uterus tilts forward during each contraction. When the laboring person is upright, the uterus contracts with gravity, not against it. When they are reclined, the uterus must work against the force of gravity with every contraction. This makes contractions more painful and less effective.

Conversely, when the laboring person is upright, squatting, kneeling, or standing, the sacrum and coccyx move freely, the pelvic outlet is at its widest, the baby's weight presses on the cervix with each contraction, and the uterus contracts in the direction it is naturally oriented. This does not guarantee a fast or easy labor. But it works with the body rather than against it.

Balaskas also noted that endorphins and oxytocin, the hormones that reduce pain and drive contractions, are sensitive to environment and emotion. A laboring person who feels watched, inhibited, exposed, or unsafe produces less of both. Darkness, quiet, a small number of familiar people, and freedom of movement support hormonal secretion. A bright clinical room with multiple strangers and an expectation of lying still works against it.

**What the birth partner can do with this:** When the laboring person gravitates toward lying down between contractions, that is reasonable rest. But if they are spending entire contractions on their back by default, this is worth addressing. Offer the shift gently: "Want to try kneeling for this one?" or "Let me help you up for the next one." You do not need to lecture about physiology. Just offer the alternative.

The Full Vocabulary of Upright Positions

Source: *Active Birth* (revised ed.) — Janet Balaskas

The standard list of "upright" options undersells the range of what is possible. Each position has a different character and serves a different purpose.

**Walking and standing.** Most useful in early labor. Walking shortens labor and increases contraction efficiency. During contractions, the laboring person can lean forward against a wall, a partner, or a doorframe. The birth partner can stand in front and let them hang from the shoulders, bending slightly and leaning back to absorb the weight. Bare feet are better than socks for traction.

**Sitting on the toilet.** Underrated and underused. The toilet seat leaves the pelvic floor completely unsupported from below, which is exactly what it needs to be during labor. The laboring person can sit forward leaning onto the partner's lap or a pillow. Effective for dilation stalls and for pushing. Every birth facility has one.

**Kneeling and all-fours.** By the time the cervix is between 6 and 10 centimeters, kneeling is what most laboring people gravitate toward naturally. Kneeling upright, kneeling forward over a ball or cushion, or on all-fours with the spine roughly horizontal. The more vertical the trunk, the more gravity assists. A more horizontal trunk slows things down slightly, which can be useful if labor is very fast. The birth partner can apply counterpressure to the sacrum from behind in any kneeling variation.

Pelvic rocking or circles during contractions while kneeling is not restless discomfort. It is the pelvis doing what it needs to do: shifting the baby's position, assisting dilation, and dispersing pain. Let it happen. Join it if you can, by placing your hands on the hips and moving with her.

**The hanging squat (facing the partner).** The laboring person faces you and puts both arms around your neck. You support them as they hang. This position is particularly useful in the second stage before the baby's head has crowned, to help the baby descend. It requires a partner who can brace. Bend your knees, keep your spine neutral, and let your legs carry the weight.

**The knee-chest position.** Head lower than the pelvis, bottom up. This slows labor down, which sounds counterintuitive but is exactly right in specific situations: anterior lip of cervix (a rim of cervix not yet dilated), an urge to push before full dilation, or labor moving so fast there is no sense of control. If the midwife identifies an anterior lip, the knee-chest position and short panting breaths, not long sustained pushes, will help the lip to retract within a few contractions.

**Side-lying.** Acceptable and sometimes necessary. If the laboring person needs rest, is exhausted in late first stage, or has been actively pushing for a long time, side-lying with a pillow between the knees allows the sacrum to move and is far better than flat on the back. It is not the most efficient position for labor, but it is not wrong.

**What to avoid:** Flat on the back for contractions, especially extended stretches of it. The semireclining position (propped on pillows to about 45 degrees) is the most common labor position in hospitals and also the least physiologically sound. It is easy for everyone in the room except the laboring person. The birth partner's job is to be the friction against that default, gently and consistently.

Standing Squat: Complete Partner Instructions

Source: *Active Birth* (revised ed.) — Janet Balaskas

The supported standing squat is the most efficient second-stage position for cases where the baby is slow to descend, is in a posterior presentation, or there is concern about progress. Balaskas documents cases where a baby born in one contraction after crowning, after a slow second stage, once the mother moved into the standing squat. The physics are simple: maximum pelvic opening plus maximum gravity.

**Before you try this, practice it.** The first time you do this should not be during labor. Practice with a partner of roughly similar weight. It will feel awkward at first, and then it will feel secure.

**Positioning yourself:**

Remove shoes and socks. Your bare feet on the floor give you the grip and sensitivity you need.

Stand with your feet two to three feet apart, more than shoulder-width. Bend your knees. Tighten the muscles of your thighs and buttocks. Lean back very slightly, enough that her weight will press back into your pelvis rather than pulling you forward. Keep your spine straight. Do not bend forward, not even a little. Bending forward shifts the load to your lower back and you will not be able to hold it.

Keep your shoulders and arms relaxed. Your legs are doing the work. Your upper body is the structure she holds, not the source of the lift.

**Passing your hands:**

From behind, pass both hands under her arms with your palms facing upward. She can rest her hands on top of yours. She can link fingers with yours. Or she can make loose fists with thumbs pointing up, and you grasp her thumbs. Use whatever grip feels stable to both of you.

**As she squats:**

When she goes into a full squat during a contraction, let her weight drop. Keep your feet flat and grounded. Your bent knees act as the shelf. If she drops very low, squat with her. Have a beanbag chair or the edge of a bed directly behind your legs so that if she drops lower than expected, you have something to lower onto together.

**After the contraction:**

Help her rise slowly back to standing or ease forward into a kneeling position. She should not come up quickly.

**If you have a weak back:**

Use the chair variation instead. Sit on the edge of a firm chair. The laboring person squats with her back resting against your body and her elbows on your thighs. Or she faces you, grasping your wrists with both hands, elbows straight, as she squats. The chair takes the load off your spine entirely.

**What you are watching for:**

Once the baby's head crowns, the birth will typically happen within the next contraction or two in this position. The baby is born in front of her, between her feet. Have a clean towel or absorbent pad on the floor. The attendant will place the baby there and you help the mother sit down to receive the baby.

Water in Labor: What the Birth Partner Should Know

Source: *Active Birth* (revised ed.) — Janet Balaskas

Water is one of the most consistently effective comfort tools in labor, and it works through a different mechanism than massage or position. The buoyancy of water removes the constant pull of gravity on the body, allowing the laboring person to float, shift, and release in ways that are not possible on land. The relief is often immediate and striking.

**When to get in:**

The general guideline, based on Odent's observations at Pithiviers and Balaskas's experience at the Garden Hospital in London, is to wait until approximately 5 centimeters dilation. Entering the water too early, in very early labor, can sometimes slow contractions by reducing the gravitational stimulus. Entering when labor is well established typically accelerates it, sometimes dramatically. Balaskas describes the pattern frequently: a woman who has been at 5 centimeters for hours enters the pool, the lights dim, the room quiets, and she reaches full dilation within the next hour or two.

**What the laboring person can do in the pool:**

All-fours over the edge, squatting holding the sides, semisitting, floating. The water makes every position easier to hold. She can squat unsupported in water in ways that would not be possible on dry ground. Encourage her to move, to find what feels right, rather than sitting still.

**If the pool is not available:**

Kneel in an ordinary bathtub. Ask the partner to pour warm water continuously over the lower back during contractions. Get the water as deep as possible. A handheld shower wand directed at the lower back during contractions is also effective and is often underestimated. The shower applies intense, focused heat and sensation that can cut through back labor and transition pain.

**Membranes:**

If the bag of waters has already released, the pool is still safe. There is no evidence of increased infection from laboring in water after rupture of membranes. The amniotic fluid is sterile.

**The goal:**

Odent was clear that the goal of the pool is not water birth. The goal is to help the laboring person get through the hardest part of labor without medication. Most women who use a pool for labor choose to get out for the actual birth, and that is fine. Whether she gives birth in the water or on land is a decision that can be made during labor, not before it.

**Third stage in the water:**

If the baby is born in the water, the baby is gently lifted to the surface within the first minute. The placental circulation continues through the cord, so there is no emergency, but the baby needs to breathe air. Hold the baby at the surface with the face and head clear of the water. The body can remain submerged. Do not cut the cord. When the cord stops pulsating and contractions resume to expel the placenta, that is the signal to leave the pool. Stand slowly. Deliver the placenta on land.

Emergency Birth: If You Are the Only One There

Source: *Active Birth* (revised ed.) — Janet Balaskas

Surprise births, where the baby arrives before any professional attendant, are almost always straightforward. The body knows what to do. So does the baby. Your job is not to manage the birth. It is to receive the baby and keep both of them warm.

**Step by step:**

Stay calm. Take several long, slow breaths. Panicking does not help and she can feel it.

Help her into the all-fours position or the knee-chest position (head lower than pelvis). Both of these give you a few extra minutes to prepare and help her feel less overwhelmed.

Close windows. Warm the room as much as you can. Babies are born warm and need to stay warm.

Get clean towels, sheets, or blankets. One to pad the floor under her. One to wrap the baby. Get a glass of water for her.

Wash your hands thoroughly.

Go back to her. Massage her lower back. Give her sips of water. Keep talking to her.

Let nature proceed. Encourage her to breathe the baby out slowly rather than push hard. Remind her to open and let go, rather than tighten and resist. If she panics, breathe deeply with her, out-breath long and audible.

As the baby's head appears, support it gently in one cupped hand. Do not pull. Do not hurry anything. Let the uterus do the work.

If the cord is around the neck, lower the baby gently face down onto a soft towel on the floor. Unwind the cord calmly from around the neck.

If she is squatting, hold the baby face down for a few moments to let fluid drain, then pass the baby up to her. If she is on all fours, pass the baby through her legs.

She should sit upright and hold the baby against her chest, skin to skin. Cover both of them, including the top of the baby's head, which loses heat fastest.

Encourage her to put the baby to the breast. This stimulates the uterus to contract and will help expel the placenta.

Call for professional help as soon as the baby and mother are stable.

If the placenta comes, place it in a bowl. Do not cut the cord. It will stop pulsating and clamp itself. After the placenta is out, the uterus should feel firm, about the size and hardness of a grapefruit. If it does not, massage her lower abdomen firmly until it contracts.

Do not leave her alone.