What is the Cook Counter Pressure technique?

Lisa Cook with tuberosity counter pressure

Lisa-Marie Cook, applying her Counter Pressure technique

Lisa-Marie Cook, a highly respected labor and delivery nurse in Washington, DC, discovered that pressing back on the pelvis in two areas seemed to help relieve pain and potentially aid rotation.

This clever pain relief technique was first shared with Penny Simkin, a physical therapist. And now, Lisa-Marie herself has given me permission to share it with you! 


Why do the Cook Counter Pressure technique?

Sometimes, there is a need to make more room for the baby to descend. Sometimes there is a need for a physical comfort measure by a support person. This technique is an easy way of doing a mild, but often sufficient amount of comfort which adds a little space by softening tight muscles. It’s not really a body balancing technique, it’s counter pressure which soothes the tight pelvic floor from outside the body, even though in rather intimate places on the body.

There may be more pain with baby’s head pressing in the lower portion of the pelvis than the birth giver can breathe through. This technique relaxes the insertion of the pelvic floor in one of two places. (We hope you did Side-lying Release before this pushing phase technique.)

Perhaps the baby, with an asynclitic (tipped) or extended (chin up) head, doesn’t have enough room to come down. A woman with a tight or somewhat smaller pelvic outlet may benefit, as well as a big baby that might appreciate this help to make a little more room.

How to do the Cook Counter Pressure technique

Lisa-Marie has identified two situations to use counter pressure on the different matching spots.

Penny teaching Gail Lisa Cook Manuever

Penny Simkin teaching Gail Tully the Cook Counter Pressure in version 1.


  1. Hold your hands somewhat flat against the sitz bones (ischial tuberosities) while the birth giver presses back into your hands for the duration of their contraction. They are on hands-and-knees. This can be done by a doula, nurse, provider or family member.
  2. Alternatively, a nurse or midwife might hold two finger pads on the inner edge of the middle to distal end of the pubic arch. If you don’t know where that means, you are unlikely to be doing this version of the counter pressure. The birth giver is on their back with legs up.

When should you do it?

  • When a birthing woman has back pain
  • When there’s a stall in labor and the baby needs help with rotation
  • During dilation phase
  • During (or close to) the 2nd stage


When should you not do it?

Don’t do this technique only if a woman doesn’t want it. Otherwise, I can’t see any reasons why not to.


Are there any good alternatives?

A good complementary technique would be the Side-lying Release.


Here’s a wonderful testimonial I think you should read:

Dear Gail,

We want to write to you about our recent experience with Lisa-Marie Cook and the Cook Counter Pressure method.

On Monday, October 18, I went into labor at 5am and labored at home until 5pm with my doula. At 5, we left for GW hospital to deliver with our midwife. I was about 7-8 cm dilated. At this point I was in active labor and not progressing much.

To my luck, Lisa was the delivery nurse assigned to us! My goal was to have a natural, drug free delivery. However, by the time I reached the hospital I was asking repeatedly for medication. In addition to the methods my doula was using, Lisa introduced us to specific counter pressure points (sitz bones, pubic arch-pushing, etc.) that provided a lot of relief.

Unfortunately, Lisa’s shift ended before delivery. However, before she left, she was able to teach these methods to my doula who was able to apply them each time I requested them. I would like to emphasize how much relief the counter pressure points provided during the delivery. I ended up having a beautiful, natural birth, but it would not been possible had Lisa not been there to teach our doula these techniques.

Best regards,

Jenny (and baby Anika)


The following excerpt is from a lovely email by the technique’s founder herself, Lisa-Marie Cook, RNC-OB:

Dear Gail,

I’ve been an avid fan of “Spinning Babies®” for several years. I’ve been teaching many of your methods here at the George Washington University Hospital in Washington, DC to our new Labor and Delivery nurses. We’ve had many successful birth outcomes because of the work you do in the birth world, thank you…

I would love to share a technique that we use here at George Washington University Hospital, and now more on the west coast thanks to Penny Simkin. My work was published in “The Labor Progress Handbook, 3rd Edition” on pages 359-363. Specifically, the “IT” counter pressure points. ( My other counter pressure point helps, but mostly during 2nd stage, doesn’t help with rotation of baby.) It helps by relaxing those pelvic ligaments, helping decrease mom’s perception of pain (especially those with back labor) and often times, between just positioning (hand/knees) and counter pressure, it helps those baby’s to rotate! Ask Penny Simkin, she had a difficult birth that she was a doula at, she used these counter pressure points and that baby delivered beautifully…She’s a believer now and published it to get the word out to doulas and labor support people.

I used it on a laboring patient last week and she said, “This helps so much.” Her doula said, “I’ve never seen that technique before, where did you learn it from?” I told her that I discovered it 6 years ago and it’s been helpful for moms that are stuck or experiencing back labor.

Thank you so much for the work that you do, it is wonderful and inspiring to see how many women have been affected by your website as doulas learn methods to help women birth. I had one of my students tell me that her baby “flipped” from breech after looking at your website…Thanks from all of us.

May your journey continue to be blessed as you touch so many lives.


Lisa-Marie Cook, RNC-OB, C-EFM, BSN, ICCE, CD

Birthing Basics, LLC

Cook Counter-pressureSM


Thank you, Lisa-Marie, for your care and service to birthing women- in your hospital, and now all around the world!

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