Counter pressure during labor involves applying steady, firm force to the lower back or hips during contractions, and research consistently shows it reduces pain during the first stage of labor. In one study, sacral counter pressure lowered pain scores by an average of 2.4 points on a standard pain scale. The technique is simple enough for any birth partner to learn, but small details about hand placement, timing, and body positioning make a real difference in how well it works.
Why Counter Pressure Relieves Labor Pain
During a contraction, the uterus tightens and the baby’s head presses against the pelvic bones and surrounding tissues. This creates deep, aching pressure that many people feel most intensely in the lower back, especially when the baby is facing the mother’s front (a position called occiput posterior, or “sunny side up”). Counter pressure works by providing an opposing force from outside the body that competes with the internal pressure signals reaching the brain. Think of it like pressing hard on a stubbed toe: the external pressure partially overrides the pain message.
The sacrum, that broad, flat triangular bone at the base of the spine just above the tailbone, is the primary target. It sits directly behind the uterus and the baby’s head, so pressing firmly into it during a contraction creates a counterbalancing force right where the internal pressure is strongest. The technique is not subtle; effective counter pressure requires genuine force, not a gentle rub.
Finding the Right Spot
The ideal location shifts as labor progresses and the baby moves deeper into the pelvis, so you may need to adjust during a single labor session. Start by locating the sacrum. If the laboring person is leaning forward, you can find it by running your hand down their spine until you reach the flat, slightly concave plate of bone between the two dimples above the buttocks. That is your target zone.
Many people describe the most effective spot as being about a hand’s width above the crease of the buttocks, but it varies. The best approach is to press firmly and ask, “Is this the right spot?” then adjust up, down, or to one side based on feedback. During back labor, when the baby’s skull is pressing against the mother’s sacrum from the inside, the sweet spot often feels very specific. Even a centimeter or two of adjustment can make the difference between relief and frustration.
The hips offer a second counter-pressure target. Pressing inward on both hip bones simultaneously, a technique sometimes called the “hip squeeze” or “double hip press,” widens the pelvic outlet slightly and can relieve a different quality of pressure. To find the right hand placement for a hip squeeze, place the heels of both hands on the fleshiest part of the buttocks, roughly where the back pockets of a pair of jeans would sit, and press firmly inward and slightly upward. This is especially useful during transition and the later stages of active labor when the baby’s head is lower in the pelvis.
How to Apply the Pressure
Technique matters more than strength. The most common mistake support people make is using their fingers or the tips of their thumbs, which causes their hands to tire quickly and concentrates force on too small an area. Instead, use the heel of one palm or stack both hands together and lean your body weight into the sacrum. This lets you sustain pressure for the full length of a contraction without exhausting your arms.
The direction of pressure should be straight inward toward the front of the body, not pushing downward toward the floor. Imagine you are trying to push the sacrum closer to the baby’s head on the other side. Some people also respond well to a slow, firm circular motion over the sacrum during a contraction, though many prefer steady, unmoving pressure. Ask and experiment early in labor so you know what works before contractions get intense enough that communication becomes harder.
Sustaining the pressure for the entire contraction matters. Counter pressure that starts strong and fades halfway through a contraction is less helpful than consistent force from start to finish. For the support person, this means pacing yourself. Trade hands, adjust your stance, and take breaks between contractions. A contraction typically lasts 45 to 90 seconds during active labor, and the break between them is your recovery window.
Using Tennis Balls and Birth Balls as Tools
A tennis ball is one of the simplest and most effective aids for counter pressure. The laboring person can lean against a tennis ball placed between their lower back and a wall, or the support person can press the ball into the sacrum with their palm. The ball concentrates the pressure into a smaller, more targeted area, which many people find more effective than a flat palm. A study of 26 women in active labor found that sacral counter-pressure therapy using tennis balls reduced pain from the severe category to moderate, a statistically significant drop.1Open Access Macedonian Journal of Medical Sciences. Decreasing Labor Pain through Sacralist Counter-pressure Therapy Using Tennis Ball in the Mother during the Labor Process
Two tennis balls placed inside a long sock, knotted at the open end, create a tool that can straddle the spine and press into both sides of the sacrum simultaneously. This is particularly useful if the laboring person wants to lean back against a wall or the back of a chair and control their own pressure. Rolling the sock-enclosed balls up and down over the sacrum between contractions can also feel soothing in a way that still differs from counter pressure during contractions.
Birth balls, the large inflatable exercise balls sometimes called Swiss balls, serve a dual purpose. Sitting on a birth ball allows the laboring person to rock their pelvis and stay upright, while leaning forward onto one lets a support person access the lower back easily for counter pressure. Research on counter-pressure techniques applied while using a birth ball found that the intervention group had significantly greater cervical dilation compared to a control group, suggesting that the combination of positioning and pressure may support labor progress as well as comfort.2Scripta Medica. Effectiveness of counterpressure technique with a birth ball on cervical dilatation and reduction of labour pain and uterine contractions: A prospective cohort study
Positions That Make Counter Pressure Easier
The laboring person’s position determines how accessible the sacrum is and how much force a support person can deliver. Some positions work beautifully with counter pressure; others make it awkward or impossible.
- Hands and knees: This is one of the best positions for receiving sacral counter pressure. The lower back is fully exposed, the support person can kneel or stand behind and lean their weight into the sacrum, and the position itself takes some pressure off the spine by letting the baby shift forward with gravity.
- Leaning forward over a ball or bed: Standing or kneeling while draped over a birth ball, a stack of pillows, or the raised head of a hospital bed opens up the lower back. This position is less tiring than hands and knees for longer periods.
- Sitting backward on a chair: Straddling a chair with a pillow over the backrest gives the laboring person something to lean into while keeping the sacrum accessible behind them.
- Side-lying: Counter pressure is possible in this position but requires the support person to press from behind, which can be less ergonomic. It works well when the laboring person needs rest between contractions and still wants sacral support during them.
The knee-chest position deserves special mention. Research on laboring women with babies in the occiput posterior position found that a knee-chest posture was associated with less back pain compared to a semi-prone position, and it encouraged the baby to rotate from a posterior to a more favorable anterior position.3PubMed Central. The Impact of Maternal Position in Labor on Occiput-Posterior Position of Fetus and Pregnancy Outcomes in Pregnant Women Without Epidural Analgesia When counter pressure is combined with a knee-chest or hands-and-knees position, you get two sources of relief at once: the position shifts the baby’s weight forward and off the sacrum, while the external pressure addresses whatever deep ache remains.
Timing Pressure With Contractions
Counter pressure is most effective when it matches the rhythm of contractions. The technique is inherently intermittent: you press firmly during a contraction and release during the rest period. This matters not just for pain relief but also for the comfort of the support person, who needs those breaks to reset their hands and posture.
Early in active labor, contractions tend to be shorter, and the laboring person may prefer to signal when they feel one starting so you can get into position. As labor intensifies, contractions often come close enough together that it helps to stay in position with your hands resting lightly on the sacrum, ready to press in as soon as the next one begins. Watch for the subtle signs: a change in breathing, a shift in posture, or a tensing of the abdomen.
Some people find that they want counter pressure only during the peak of a contraction, not the whole buildup. Others want it from the very first twinge until the contraction fully passes. There is no single correct timing, and the preference often changes as labor progresses. The most useful thing a support person can do is stay attentive and responsive rather than locking into one pattern.
What the Research Shows About Effectiveness
Counter pressure has been studied in several clinical settings, and while the trials tend to be small, the direction of the findings is consistent. A study at an Indonesian hospital found that sacral counter pressure reduced pain scores by an average of 2.4 points on a standard pain scale during the first stage of labor, a statistically significant result.4Acta Medica Iranica. Reducing Pain in the First Stage of Labour Using Counter-Pressure Therapy in the Indonesian Hospital The tennis ball study mentioned earlier found that all participants, who entered the study reporting severe pain, dropped to the moderate category after receiving the intervention.1Open Access Macedonian Journal of Medical Sciences. Decreasing Labor Pain through Sacralist Counter-pressure Therapy Using Tennis Ball in the Mother during the Labor Process
These are not large randomized controlled trials with thousands of participants, so the findings should be understood as promising rather than definitive. But the consistency across different clinical settings and populations, and the fact that counter pressure carries essentially no risks, makes it one of the most practical non-pharmacological options available. It costs nothing, requires no equipment beyond a willing pair of hands, and can be started or stopped instantly.
Research on broader doula-supported labor, which typically includes counter pressure as one of several hands-on techniques, has found that increased use of complementary comfort measures is associated with lower epidural use.5Complementary Therapies in Clinical Practice. Lower epidural anesthesia use associated with labor support by student nurse doulas: Implications for intrapartal nursing practice This does not mean counter pressure replaces epidural analgesia. It means that for people who want to manage pain without or before pharmacological intervention, having a support person who knows counter pressure and similar techniques makes a measurable difference.
Combining Counter Pressure With Heat and Cold
Counter pressure does not have to work alone. Applying a warm pack to the lower back between contractions and then switching to firm counter pressure during the contraction itself gives the muscles time to relax between bouts of intense pressure. Research on alternating heat and cold during labor used warm packs at 38 to 40 degrees Celsius on the lower back for 30 minutes during the first stage, followed by cold packs for 10 minutes, cycling back and forth throughout labor.6PubMed Central. The effect of intermittent local heat and cold on labor pain and child birth outcome While that study focused on heat and cold rather than counter pressure specifically, the principle translates: warmth relaxes the muscles of the lower back, and relaxed muscles mean counter pressure can reach deeper and feel more effective.
In practice, a simple approach is to keep a warm rice sock or heated water bottle tucked against the lower back during rest periods, remove it when a contraction starts, and apply firm sacral pressure for the duration of the contraction. The alternation between soothing warmth and deep targeted pressure gives the laboring person two different types of relief in a rhythm that matches the natural ebb and flow of contractions.
When Counter Pressure Helps Most and When It Does Not
Counter pressure tends to be most effective during back labor, which occurs when the baby is in an occiput posterior position. In this presentation, the hard back of the baby’s skull presses directly against the mother’s sacrum, creating intense back pain that often does not fully let up between contractions. People experiencing back labor frequently describe counter pressure as the only thing that helps, and it is worth the support person’s fatigue to keep providing it.
It also tends to work well during the active phase of the first stage of labor, roughly from about four centimeters of dilation onward. In very early labor, contractions are usually mild enough that counter pressure is unnecessary. During the pushing stage, the laboring person’s focus shifts and the pain changes character; counter pressure on the sacrum becomes less relevant, though a hip squeeze can still help.
Counter pressure is less helpful for people whose labor pain is concentrated in the front of the abdomen rather than the back. If the baby is already in a favorable anterior position, the internal pressure on the sacrum is minimal, and pressing on it does not produce the same dramatic relief. In these cases, other comfort measures like movement, warm water, and position changes tend to be more useful. There is no harm in trying counter pressure regardless of fetal position, but if the laboring person says it is not helping, believe them and move on to something else.
Advice for the Support Person
Providing sustained counter pressure through hours of labor is physically demanding. Support people commonly develop sore hands, aching forearms, and tired shoulders, especially if they rely on finger or thumb pressure rather than leaning their body weight. A few practical strategies help.
First, protect your own body mechanics. Stand with your feet about hip-width apart, bend your knees slightly, and lean forward from the hips rather than rounding your back. Use your upper body weight to generate force rather than pushing with your arm muscles. If you are pressing into the sacrum with stacked palms, your arms should be relatively straight, with the force coming from your lean rather than from muscular effort.
Second, trade off with another support person if one is available. A doula, a family member, or even a nurse who is willing can give you breaks without the laboring person losing continuity of care. The tennis-ball-in-a-sock trick mentioned earlier is also valuable here because the laboring person can lean against it on their own during short breaks when no one’s hands are available.
Third, communicate calmly and specifically. Instead of asking “how are you doing?” during a contraction, which forces someone in intense pain to formulate a response, try yes-or-no questions: “More pressure?” “Higher?” “Is this the right spot?” Between contractions, ask broader questions about what is and is not working. Many people in active labor lose the ability or desire to articulate complex preferences, so keeping the feedback loop simple helps both of you.
Finally, do not take it personally if the laboring person suddenly does not want to be touched at all. Preferences can change from one contraction to the next. The shift from “press harder” to “don’t touch me” is a normal part of labor progression, especially during transition. Step back, stay close, and be ready to resume if they ask. The best support person is one who can read the room and adapt without needing explicit instructions for every shift.