PDF Summary:The Birth Partner, by Penny Simkin

If you're preparing to support someone through labor and delivery, you may feel uncertain about what to expect and how to help. In The Birth Partner, Penny Simkin provides guidance for birth partners—whether you're a spouse, family member, friend, or doula—on how to prepare for and actively support someone through childbirth.

Simkin explains the stages of labor and delivery, describes how birth partners can help manage pain and discomfort, and outlines ways to support the birthing person's emotional and physical needs. She also covers medical interventions like cesarean births and VBACs, and discusses postpartum recovery and breastfeeding challenges. This guide will help you understand your role and equip you to provide meaningful support during one of life's most significant experiences.

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The Evolution of the Birthing Stage

The concept of the birthing stage, with its three phases—resting, descent, and crowning and birth—has evolved over time. In the 1950s, obstetrics researchers began to study the progression of labor in detail, leading to the development of the "labor curve." This curve established expectations for how quickly labor should progress, including the duration of the birthing stage. The idea that the baby's head position or epidural use could prolong this stage also emerged from these early studies. However, more recent research has challenged these rigid timelines. In 2010, obstetric researchers published a medical research article in an academic paper that found that labor often progresses more slowly than previously thought, especially in the early stages. This has led to a reevaluation of what constitutes "normal" labor progression and a greater emphasis on individualized care.

Interventions and Options in Labor and Delivery

Simkin notes that someone who has delivered via cesarean may be able to deliver vaginally. A vaginal birth after cesarean (VBAC) is a vaginal birth following a previous cesarean, while a trial of labor after cesarean (TOLAC) is an effort to have a vaginal birth following a previous cesarean. Some attempts encounter labor complications, necessitating a C-section. In the past, policy required delivering all future babies via cesarean for anyone who'd already had one or more cesarean births. This was due to the highly invasive nature of surgical techniques at that time, which left a sizable scar in the upper uterus that posed a significant risk of reopening (rupturing) in future labors.

(Shortform note: In Cesarean Section, Jacqueline H. Wolf explains that the rule that every later birth had to be a cesarean after one cesarean was established in the early 20th century. In 1916, New York obstetrician Edwin Cragin coined the phrase “once a cesarean, always a cesarean.” This phrase was repeated in articles, lectures, and textbooks, and hospitals wrote it into their protocols. Wolf notes that this rule was established before there was much data on the outcomes of vaginal births after cesarean. She argues that the rule persisted for decades because of institutional inertia and fear of malpractice lawsuits, rather than solid evidence.)

C-sections have evolved throughout history. The ACOG (American College of Obstetricians and Gynecologists) now claims that for many people, delivering the second baby vaginally is not only feasible but also safer, as a second cesarean presents greater risks to healthy individuals than a vaginal delivery. Their 2017 Practice Bulletin endorses VBAC and TOLAC. It offers safety instructions to obstetricians and outlines optimal procedures to include VBACs and TOLACs to enhance outcomes. However, some individuals aren't suitable for a TOLAC. The ACOG advises thorough assessment of the eligibility for a TOLAC of each pregnant person who's previously had a cesarean.

(Shortform note: A Practice Bulletin is a clinical guideline that ACOG publishes to inform obstetrician-gynecologists about the management approach that ACOG currently recommends on a specific topic. These bulletins are based on the best available evidence and expert consensus. They provide recommendations on a wide range of topics, including prenatal care, labor and delivery, postpartum care, and gynecologic conditions. Practice Bulletins are intended to help clinicians make informed decisions and provide high-quality care to their patients.)

Factors taken into account include the pregnant person's present health, reasons for their first cesarean, whether those reasons (like certain ongoing illnesses, anatomical issues with the pelvis, uterus, spine, etc.) still apply, how the person recovered after the cesarean, the availability of a hospital and staff that back VBAC and can conduct a cesarean any time, and proximity of the hospital to the parents' residence. If these conditions aren't met, ACOG advises having another cesarean. When these conditions are favorable, there's a good chance for a successful VBAC, and a TOLAC is more beneficial than risky. Although these safeguards are in place, there's no assurance that all who meet the criteria will experience a VBAC. The decision to pursue a TOLAC should follow a comprehensive discussion between the birthing parents and their caregiver.

(Shortform note: One way to structure this comprehensive discussion is to use a VBAC prediction tool. These tools use the conditions listed above to calculate the probability of a successful VBAC. The authors of a 2007 study on VBAC prediction tools suggest that these tools can help clinicians and patients make informed decisions about the mode of delivery. By providing an individualized estimate of the likelihood of a successful VBAC, these tools can help birthing parents weigh the benefits and risks of a TOLAC against the alternative of another cesarean. This approach can help ensure that the decision to pursue a TOLAC is based on a thorough understanding of the potential outcomes and aligns with the birthing parents' values and preferences.)

VBACs offer a number of important advantages, such as avoiding the many immediate and future risks linked to major abdominal surgery. Additionally, healing after a vaginal delivery is simpler and quicker compared to a C-section. Additionally, if the cesarean deeply disappointed them, a VBAC might help them heal emotionally. In the U.S., 60–80% of people who try TOLAC can successfully have a VBAC.

(Shortform note: A VBAC might help ease the emotional pain of a disappointing cesarean by allowing the person to “reclaim” childbirth on their own terms. This could help them transform a traumatic experience into a less distressing life story. For example, if someone felt powerless during their cesarean, a VBAC might help them feel more in control. This could help them see their birth story as one of overcoming challenges rather than being defined by trauma.)

Despite the safety and long-term benefits of VBAC, only a small number of people in the U.S. are given the chance to attempt a trial of labor after cesarean, or decide to, so only around 12 percent of pregnant individuals who had a cesarean birth will experience a vaginal birth after cesarean. Conversely, many nations in Europe have a greater number of attempts (TOLACs), and six countries' VBAC percentages range from 29 to 55.

(Shortform note: The statistics in this section may be outdated. In recent years, public health researchers and demographers have noted that VBAC rates in the US vary widely by state, with some states having rates as high as 20% and others as low as 5%. This variation is likely due to differences in hospital policies, provider attitudes, and patient preferences across regions. While the overall US VBAC rate remains lower than in many European countries, some states are approaching those higher rates, suggesting that with supportive policies and practices, VBAC can be a more common option for birthing people in the US.)

There are many factors contributing to the low VBAC rate in the United States relative to other industrialized countries, but it seems likely that the rate will rise, in part because the American College of Obstetricians and Gynecologists has issued Practice Bulletins over time that have increasingly advocated for VBAC and TOLAC. With backing from the organization representing obstetricians, more doctors feel comfortable performing VBACs. In other words, if someone giving birth desires a vaginal delivery following a C-section, they're likely to find a caregiver who will support them, especially in many cities.

(Shortform note: This may be true in many places, but in Cut It Out, Theresa Morris points out that in some communities, there are no hospitals that allow labor after a previous C-section. This is because some hospital administrators and malpractice insurers have adopted blanket policies that prohibit VBAC, so individual physicians and midwives are not allowed to offer a trial of labor even when they personally support it, the patient is well-informed, and the clinical risk is low. These institutional bans can leave entire regions without any facility that permits VBAC, forcing women either to consent to a repeat cesarean they do not want or to travel long distances to find a hospital that will accommodate their preference for labor after a previous cesarean.)

Most labors after a cesarean are uneventful, but there's a slight added risk since the uterus is scarred from the surgery. The main concern with a VBAC is the chance of the scar reopening, sometimes called a uterine rupture. The risk of the scar separating is around 1 in 200, or 0.5 percent, and it's slightly greater in those who've had multiple cesareans.

(Shortform note: The American College of Obstetricians and Gynecologists (ACOG) has updated its guidelines to emphasize that the risk of the uterine scar reopening is an average, not a fixed number. They recommend that clinicians use individualized risk assessments to provide more accurate counseling for each person. This approach takes into account factors like the type and number of previous cesareans, the reason for the first cesarean, and other aspects of the person’s medical history.)

However, by closely observing the birthing individual and the fetal heartbeat, medical professionals can usually catch a scar separation in time to conduct a cesarean and repair it. Although they can be concerning, most instances of scar separation have positive outcomes, with both the baby and the birthing person remaining healthy, due to prompt and correct action. In very rare cases, the scar can open enough to lead to a crisis for the fetus (or its death) and/or severe blood loss for the birthing person. Carefully screening the pregnant individual beforehand allows the provider to determine those with heightened risk of these complications. During labor, the scar on the uterus may occasionally thin without breaking, and when this happens, it self-repairs as it goes back to its nonpregnant condition.

Using Ultrasound to Predict Scar Separation

In an academic paper, researchers reviewed studies that used ultrasound to measure the thickness of the lower uterine segment (LUS) in pregnant people who had previously had a cesarean. They found that the thinner the LUS, the more likely it was to separate during labor. This suggests that by measuring the LUS before labor, doctors can identify those who are at higher risk of scar separation. The researchers concluded that while LUS thickness alone isn’t enough to predict scar separation, it can help doctors identify a subgroup of pregnant people who are particularly vulnerable. This means that by carefully screening the pregnant individual beforehand, doctors can better determine who might need extra monitoring or care during labor.

Partnering for Ease & Wellbeing

Simkin notes that partners can assist laboring people in handling discomfort and enhancing their wellbeing. When someone in labor comprehends the reason for contraction pain and receives constant nurturing and support from compassionate, confident individuals in a calm and secure setting, fear is replaced by mastery, confidence, and well-being. Although the contractions are extremely intense, the laboring individual doesn't experience suffering—they manage. Partners can support by staying with them during labor, providing emotional support, comforting them with massages, holding their hand, offering hot or cold packs, recommending a bath or shower, and helping them use other comfort measures.

Unrealistic Expectations

While Simkin’s advice is well-intentioned, it may inadvertently set up unrealistic expectations for both the laboring person and their partner. If the laboring person still feels overwhelmed or distressed despite their partner’s best efforts, they may internalize this as a personal failure. This can lead to feelings of guilt, shame, and even post-traumatic stress symptoms. Beck found that women who felt they had failed during childbirth often experienced intrusive memories, nightmares, and avoidance behaviors, even when their birth was medically uncomplicated. Partners may also feel inadequate if they believe they should have been able to prevent their loved one’s suffering.

Next, we’ll discuss comfort and strategies for handling discomfort, along with obstacles and recovery.

Comfort & Coping Strategies

Simkin explains that shifting positions and moving can help you feel better and facilitate labor. Changing positions may allow you to discover what feels best, ease discomfort, and aid labor advancement. You can be on your feet, move around, take a seat, crouch, bend down, lie on your side, go on all fours, or lean against something.

(Shortform note: If you’re on your feet and moving around, be aware of the risk of falling. For example, if you have an epidural, you may not be able to feel your legs, which can make it difficult to walk and increase your risk of falling. If you fall, you could injure yourself or your baby.)

You can also gently sway side to side. Standing and walking employ gravity to help the baby move down. Walking also aids in the infant's rotation and downward movement. Leaning forward can alleviate back pain. Squatting widens the pelvis and uses gravity to assist in the baby's downward movement. Sitting upright or using a toilet can help you rest and relax your pelvic muscles. Lying on your side allows you to rest and reduce your blood pressure. Being in a hands-and-knees position can ease back pain and assist in rotating the baby. Rocking or swaying may aid relaxation and improve your mood. Switching positions roughly every half hour can be beneficial. During labor, you might employ a variety of postures, particularly if this phase lasts over an hour.

The Benefits of Movement and Positioning During Labor

The fact that people in different cultures, when not confined to beds, tend to arrange their bodies in similar ways during labor suggests that these positions are beneficial. In her book Birth in Four Cultures, anthropologist Brigitte Jordan describes how, in the 1970s, she and her colleagues observed births in the United States, Sweden, the Netherlands, and Yucatan, Mexico. They found that, when not confined to beds, laboring people in all four cultures tended to arrange their bodies in similar ways. For example, they often leaned forward, squatted, or knelt. They also frequently changed positions, moving around the room or shifting their weight from side to side. Jordan and her colleagues concluded that these similarities were unlikely to be coincidental. Instead, they suggested that these positions and movements were likely beneficial for labor, as they had been adopted independently by people in different cultures.

Responding to Challenges & Recovery

Simkin explains that during the postpartum phase, both the newborn and birthing parent are monitored. After delivery, the laboring individual remains in the delivery or recovery area for several hours, with a nurse nearby. The nurse monitors their heart rate, body heat, blood pressure levels, uterus firmness, and anesthesia status. The nurse also monitors the baby’s breathing, skin color, body temperature, and heartbeat. Depending on the hospital's practices and the baby's condition, the baby might stay with the parents or be taken to the nursery for monitoring or care.

(Shortform note: Uterus firmness refers to how tight the uterus feels when the nurse presses on the birthing parent’s abdomen. A firm uterus is a good sign because it means the muscle is contracting well, which helps stop bleeding after birth. After delivery, the uterus needs to contract to clamp down on blood vessels where the placenta was attached. If the uterus is soft or “boggy,” it means the muscle isn’t contracting well, which can lead to excessive bleeding. The nurse checks the uterus by pressing on the abdomen to feel if it’s firm and round, like a grapefruit.)

Pain relief measures will be planned to ensure the birthing person is comfortable. The new parent is able to begin nursing, and nurses or a doula can assist with positioning and initiation. Starting to breastfeed before the anesthesia has worn off can be beneficial, since it will be somewhat easier to begin without pain. If the birthing person is unable to nurse or hold the infant, you can do it. Hold your infant (if possible, in direct contact with your skin) and speak or sing to them. Once the anesthetic effects have faded and the birth-giver is in a stable condition, they'll be moved to the postpartum room and remain there until they leave the hospital.

(Shortform note: If the birthing person is still sedated from anesthesia, early breastfeeding or skin-to-skin contact can increase the risk of accidental airway obstruction. This is because the birthing person may not be fully alert and able to respond to the baby's movements or needs. If the birthing person is still under the effects of anesthesia, they should be closely monitored by medical staff during any early breastfeeding or skin-to-skin contact.)

Simkin notes that breastfeeding can be challenging and requires endurance and support. New parents might be taken aback by how much time breastfeeding takes. Infants don’t breastfeed on a consistent schedule. They might nurse multiple times back-to-back and then not eat for a fairly extended period. A common pattern is that a baby will feed four times within a six-hour period and then sleep for three to four hours before feeding again. Frequent breastfeeding, even before colostrum transitions to breast milk, helps prevent severe engorgement.

(Shortform note: The La Leche League International (LLLI) explains that engorgement occurs when the breasts become overly full and swollen with milk, blood, and lymph fluid, so that they may feel hard, hot, and painful and the skin can look stretched and shiny, sometimes making the areola so tight that the baby has difficulty latching because of the increased pressure inside the breast tissue. This can happen when the body is still producing colostrum (the first milk) in small amounts, but then suddenly starts producing larger volumes of mature milk. The rapid increase in milk production can overwhelm the breast tissue, leading to engorgement. This is why frequent breastfeeding, even before the transition to mature milk, is important to help prevent severe engorgement.)

However, the baby's hunger and breastfeeding capacity might initially not align with the milk supply. The breasts may be painfully overfull, which can make it hard for the baby to nurse. Nipple discomfort can result from an improper latch or extended, intense nursing. Some infants have a more powerful and longer-lasting sucking reflex than others. Initial nipple pain could be more intense with these infants; however, it should subside after your milk starts flowing or within about a week if they're latching properly.

(Shortform note: Another cause of nipple pain is tongue-tie, a condition in which the tissue connecting the tongue to the floor of the mouth is too tight, restricting the tongue's movement. This can make it difficult for the baby to latch properly and can cause significant nipple pain for the mother. La Leche League notes that tongue-tie can cause ongoing nipple pain and damage even when the baby appears to be latched well. Signs of tongue-tie include nipples that come out of the baby's mouth flattened, ridged, or with a white line across the tip, clicking or slipping sounds during feeds, or persistent pain that doesn't improve.)

Pain is generally typical if it happens during the initial minute of nursing but decreases throughout the remainder of the session. If the pain lasts for the entire time you're breastfeeding, the cause might be an ineffective latch. When an infant bites or loses suction, it may increase nipple discomfort. This could decrease milk production. A healthcare professional, like a nurse, midwife, lactation consultant, or prenatal instructor, as well as quality literature on breastfeeding, can help with the quality of latching. If you're experiencing severe soreness and have cracked or bleeding nipples, promptly seek help from a lactation specialist. Decreasing or ceasing breastfeeding without pumping milk may cause engorgement and decrease milk supply. If a breastfeeding specialist or another healthcare provider recommends modifying your breastfeeding routine, they should also suggest that you pump and use a bottle to feed your baby for the duration of this change.

(Shortform note: The idea that some pain is normal and some pain is not, and that you should pump if you can’t nurse, is a relatively recent development in the history of breastfeeding. In Lactivism, Courtney Jung explains that in the 1970s, breastfeeding was a relatively rare practice in North America. However, a coalition of middle-class mothers, feminist health activists, and international health organizations began to promote breastfeeding as a public health and moral issue. This led to the development of programs like the Baby-Friendly Hospital Initiative and the professionalization of lactation consultants. These efforts helped to create the rules and guidelines that now exist around breastfeeding, including the idea that some pain is normal and some pain is not, and that you should pump if you can’t nurse.)

Consider using nipple shields—these are silicone covers with small openings that let milk pass through. They can shield the nipple area from more harm while nursing. It's recommended to speak with a lactation specialist if you're considering using these shields. If necessary, consult your healthcare provider regarding pain medications. If these methods don't work, consult a lactation specialist, birthing class teacher, or the child's physician, or look for a helpful book on breastfeeding.

(Shortform note: If nipple pain continues despite these methods, ask for your baby’s mouth to be examined for problems such as tongue-tie. The National Health Service (NHS) recommends that if tongue-tie is suspected, the baby should be seen by a healthcare professional with specific training in assessing and treating tongue-tie. These professionals can confirm the diagnosis and, if necessary, perform a simple procedure called a frenulotomy to release the tongue-tie and help improve feeding.)

The 24-hour "cure" can help address various issues, such as concerns about sufficient milk production, tiredness, sleeplessness, worry, appetite loss, poor nutrition, inadequate hydration, the infant gaining weight slowly, or "nipple confusion" (the infant appears to favor a bottle nipple or nipple shield instead of breastfeeding). The “cure” encourages regular, effective nursing and an ample supply of milk by nurturing both the nursing parent and the baby.

(Shortform note: The 24-hour “cure” is similar to the “nursing vacation” that La Leche League International popularized in its book The Womanly Art of Breastfeeding. The book, first published in 1958, was one of the first to provide comprehensive information on breastfeeding and has been updated regularly to reflect new research and practices. The concept of a nursing vacation has been part of breastfeeding literature for decades, emphasizing the importance of rest, skin-to-skin contact, and frequent nursing to address common breastfeeding challenges.)

The parent is relieved of all duties except feeding and cuddling their baby and receives total rest as well as plenty of healthy meals and beverages. The baby gets prolonged skin-to-skin contact with the breastfeeding parent, constant access to the breast, and nurturance. Prior to beginning, ensure the baby is putting on weight—even gradually—by tracking their weight over a few days. If the baby isn’t putting on weight, talk to their doctor or a lactation consultant prior to starting the cure. Also ensure the nipples aren't sore, cracked, or blistered, as these issues must be resolved before starting this remedy. Allocate an entire day to provide support to the breastfeeding parent and baby during this healing process. Take time off work, or ask a friend, family member, or postpartum doula to cover part of the 24-hour period.

(Shortform note: Since the publication of the 5th edition of The Birth Partner, new recommendations have been made regarding infant sleep safety. While prolonged skin-to-skin contact and constant access to the breast are beneficial, it’s important to ensure the baby is placed on a flat, firm sleep surface whenever the adult is drowsy or likely to fall asleep. This precaution helps prevent accidental suffocation or entrapment, which can occur if a parent falls asleep while holding the baby. The 24-hour cure can still be effective, but it’s essential to balance close contact with safe sleep practices. Consider setting up a safe sleep area nearby, such as a bassinet or crib, so the baby can be easily placed down when the parent needs to rest.)

Constant support is crucial. The baby and breastfeeding parent lie down. They both wear minimal clothing beneath the covers, maximizing warm skin-to-skin contact for the baby, which triggers the suckling reflex and increases interest in feeding. The breastfeeding parent can read books, watch television, or have conversations with you or other supportive people, though No visitors, and the main thing is to doze. Extra sleep can significantly help, even if it's in brief intervals. The parent who's nursing should remain in bed, even if falling asleep is taking a while. Sleep-deprived people might need time to unwind and fall asleep.

(Shortform note: The American Academy of Pediatrics (AAP) would likely disagree with this advice. The AAP recommends that infants sleep in the same room as their parents but on a separate, firm sleep surface, such as a crib or bassinet, to reduce the risk of suffocation and sudden infant death syndrome (SIDS). The AAP acknowledges that breastfeeding parents may fall asleep while feeding their baby in bed, but they recommend moving the baby to a separate sleep surface as soon as the parent wakes up. The AAP also warns that couches and armchairs are particularly dangerous places to fall asleep with an infant.)

The person nursing should aim to only leave bed to use the restroom—not to have meals, answer calls, do chores, or any other activity. Supply plenty of liquids—place water or juice within reach with a goal of having the lactating parent drinking about 2 to 3 quarts (1.9 to 2.8 L) during the 24 hours. Offer tasty, nutritious meals. If your household has been relying on takeout and cold, ready-to-eat options, they'll appreciate a couple of warm, homemade dishes. If you’re not a great cook, there are lots of nutritious options you can try.

(Shortform note: The Royal College of Obstetricians and Gynaecologists (RCOG) warns that the risk of venous thromboembolism (VTE) is significantly higher in the postpartum period, especially in the first six weeks after birth. This risk is further increased by factors such as cesarean section, obesity, inherited or acquired thrombophilia, prolonged immobility, and postpartum hemorrhage. The RCOG recommends that women with multiple risk factors should receive appropriate thromboprophylaxis and be encouraged to mobilize as early as clinically possible. Therefore, the advice to “only leave bed to use the restroom—not to have meals, answer calls, do chores, or any other activity” for a full 24 hours could potentially increase the risk of VTE in some postpartum women.)

The baby ought to remain in bed with the breastfeeding parent, except for when a diaper change is needed or the baby is cranky and not wanting to nurse and needs to be rocked or walked for a short time. Then, you should tend to the baby. When your infant wakes up or shows any interest in nursing, they should breastfeed.

(Shortform note: This advice doesn’t apply if the breastfeeding parent is taking medications that reduce arousal, such as sedatives or opioids. The American Academy of Pediatrics (AAP) recommends against bed-sharing in these cases. These medications can make it harder for parents to wake up and respond to their baby’s needs, increasing the risk of accidental suffocation or other sleep-related incidents.)