Cook Counter-pressure

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

A well balanced forum of instruction and caring.

Cook Counter-pressure as a Comfort Method in Labor©

Cook Counter-pressure^SM Stage One

The Cook Counter-pressure^SM 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.

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.

How

Cook Counter-pressure^SM Stage One 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. 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 Counter-pressure^SM Number 1 - Ischial Tuberosities (I-T)

· During any phase of labor- early, active, and especially transition when a woman is complaining of pelvic pressure or back pain.

· 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 Counter-pressure^SM Stage One 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.

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

When not to use Cook Counter-pressure^SM Number 1 - Ischial Tuberosities (I-T)

· 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.

Contraindications:

· 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 Counter-pressure^SM Stage One can also be used on the Ischial tuberosities when pushing prior to crowning. This often helps to alleviate pelvic pain and pressure between contractions.

Stage One utilizes the ischial tuberosities, Stage Two counter-pressure is directed at the pubic arch, on the Mediolateral sides of the labia with pressure directed downward towards the descending rami. Anatomically, as the fetal head, or presenting part, descends into the pelvic outlet and crowning begins, the perineal muscles and ligaments of the pelvic floor get stretched particularly the Ischiocavernosus muscle which originates from the ischial tuberosity and descending ramus , and the transversus perinea superficialis which is the strip of muscle that creates the central tendon of the perineum.

Stage Two

As the pelvic floor and the perineum stretch during contractions with fetal descent, it is the Cook Counter-pressure^SM Stage Two technique used at the descending rami that counteracts the forces of the presenting part against the pubic arch and pelvic musculature. As the fetal head crowns, causing the “ring of fire” or perineal ‘burning”, Stage Two counter-pressure creates a perception of decreased pain at the perineum by the laboring woman.

How

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 Counter-pressure^SM is used either as continuous or intermittent pressure during and also in between the contractions. The Cook Counter-pressure^SM Stage Two technique is highly effective when applied during and in between contractions while a woman is pushing, but is found most effective when crowning. The woman tells the caregiver how hard to exert pressure and whether it is more effective when used during contractions or in between contractions.

When to use Cook Counter-pressure^SM Number 2 - Perilabial (P-L)

· 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 Counter-pressure^SM Number 2 - Perilabial (P-L)

· 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.

Contraindications:

· 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.

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-Copyright and Trademark Statements Year Published/Completed: 2010, previously registered in 2009 Author: Lisa-Marie Sasaki Cook

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