Cook Counter Pressure


Lisa identifying ischial tuberosities (I-T) and utilizing counter pressure with her thumbs.

The Cook Counter-pressure  techniques are an alternative, non-pharmacological, no cost, non-invasive method of relieving back and pelvic pain for laboring women during the first and second stages of labor. Since it’s publication on Spinning Babies, I’ve been asked, “HOW EXACTLY does this work”?

So here’s the LONG version of it:

Located on the posterior side of the thigh, at the midpoint of the inferior gluteal fold, UB 36 (Urinary Bladder 36) known by the Chinese Name “Chengfu”, is also identified with the English Names “Receiving Support” or “Supporting by Hand”. This point, when activated, has been identified to alleviate pain in the lower back and gluteal region; constipation; muscular atrophy; numbness and motor impairment of the lower extremities. In clinical practice, physiotherapists have identified UB 36 as a “trigger point” or local point with a wide spectrum of activity to help release the gluteus maximus muscle. The ischial tuberosities are also the point of attachment for three major pelvic ligaments and the hamstring tendons. When counter-pressure is applied to this site, it directly counteracts the uterine contraction forces on the ligaments with fetal head descent in the pelvis.


First, identify the ischial tuberosities or sitz bones with the patient’s legs bent, they are the bony protrusions that you’ll feel at the base of their buttock. This point in TCM is also known as UB-36 point “Cheng fu”

How to use I-T Counter-pressure:

-Cook I-T Counter-pressureSM requires that the laboring woman place herself into a position with flexed knees—into a side-lying, hands-knees position, open knee-chest, or squatting position.

-These positions help expose the woman’s “sitz bones” or ischial tuberosities. By having the knees flexed, the large gluteus maximus muscles move away from the ischial tuberosities exposing them so that the large bony protrusions can be easily palpated.


Lisa identifying Heidi’s I-T points in a side-lying position, then using the palms of her hands to provide counter- pressure.

-After identifying the ischial tuberosities, the woman’s caregiver then places the pads of his/her thumbs, the heel or fists of their hands on the woman’s skin and gradually leans in towards the ischial tuberosities or “sitz bones” exerting either a steady or intermittent pressure during a contraction and /or in between contractions The woman tells the caregiver where to push and how hard to push on these points. (** Tennis balls can be also be used to press against these points.)

When to use Cook’s I-T Counter-pressure SM:

•During any phase of labor- early, active, transition and pushing when a woman is complaining of pelvic pressure or back pain. It helps when women are “stalled” at any dilation, especially transition.

•During the first stage of labor when a woman feels like bearing down or has an urge to push and is not yet 10 cm dilated.

•During second stage of labor during contractions if a woman is pushing and the “sitz bones” are exposed–side-lying, squatting, hands-knees, open knee-chest or lithotomy positions. *Note: Women find that Cook’s I-T Counter-pressure SM provided to the ischial tuberosities between contractions also helps to decrease the amount of pelvic pressure that they experience and are better able to relax between contractions while pushing.


IT counter pressure when pushing

•When a woman is complaining of back or pelvic pressure even with epidural anesthesia.

When not to use Cook’s I-T Counter-pressure

•When the woman states that counter-pressure is not alleviating pain, or when she finds that it is distracting.
•When the woman states that it is causing discomfort.
•Pre-existing symphysis pubis problems
•Past pelvic / sacroiliac / chronic low back pain
•Past trauma (car accident, obstetric trauma, etc.) that may have damaged the pelvic girdle area.



Cook’s Peri-Labial (P-L) Counter-pressure
As the pelvic floor and the perineum stretch during contractions with fetal descent, it is the Cook’s Peri-Labial Counter-pressure technique used at the descending rami that counteracts the forces of the presenting part against the pubic arch and pelvic musculature. The Ischiocavernous muscle, transverse perineus muscle, sacrotuberous ligament,  and levator ani muscles are all attached to the ischial tuberosity.  Counter pressure applied when the fetal head crowns, during the “ring of fire” or perineal ‘burning”, will actually decrease the perception of  pain at the perineum.  It’s truly wonderful for natural childbirth patients.

Peri-labial counter-pressure point, located on the descending rami, midpoint on the lateral side of the labia.

Peri-labial counter-pressure point, located on the descending rami, midpoint on the lateral side of the labia.

How to provide peri-labial counter pressure:
-During the second stage of labor, with the laboring woman in a lithotomy, side-lying or squatting position, the caregiver uses the pads of their thumbs or index fingers from both hands, or, in a single-handed technique, the pads of their thumb and middle finger or thumb and index finger to provide counter-pressure mediolaterally on the external labia down towards the descending rami of the pubic arch below the adductor longus insertion site.


-Cook’s P-L Counter-pressure SM can be use either as continuous or intermittent pressure during and also in between the contractions.

-The Cook’s P-L Counter-pressure SM technique is highly effective when applied during and in-between contractions while a woman is pushing, it is found most effective when crowning. Right when the women says, “it’s burning”…it’s truly awesome then. The woman tells the caregiver how hard to exert pressure and whether it is more effective when used during contractions or in between contractions.  Many times I’ll extert counter pressure while applying a warm compress…Combined, it’s heaven.


When to use Cook’s Peri-Labial Counter-pressure SM
•When the woman is involuntarily pushing with contractions or feels an urge to push or bear down and she is not yet 10 cm dilated.
•When the woman is in the second stage of labor and pushing, either during contractions or in between contractions
•When the woman is crowning between contractions.

When not to use Cook’s Peri-Labial Counter-pressure
•When the woman reports that counter-pressure is uncomfortable, not helping, or when she finds it distracting.
•When the midwife or physician requests the caregiver to stop utilizing the technique for delivery of the baby.
•If there has been prior injury to the pelvis, or a history of Symphysis Pubis Disorder.
•Pre-existing symphysis pubis problems
•Past pelvic / sacroiliac / low back pain
•Past trauma (car accident, obstetric trauma, etc.) that may have damaged the pelvic girdle area.

Stimulating these points using counter-pressure may be offered as a viable pain relief option in the birthing room. For those in the field of obstetrics, these new counter-pressure techniques create a new method of non-invasive, non-pharmacological pain relief techniques to support laboring women during their childbirth journey.

Please leave a REVIEW, like & share: