Cover Page

The Labor Progress Handbook

Early Interventions to Prevent and Treat Dystocia


Fourth Edition

Penny Simkin, BA, PT, CCE, CD(DONA)

Senior Faculty, Simkin Center for Allied Birth

Vocations at Bastyr University

Independent Practice of Childbirth Education and Labor Support, USA

Lisa Hanson, PhD, CNM, FACNM

Professor and Director, Midwifery Program

Marquette University, USA

Ruth Ancheta, BA, MA, ICCE, CD(DONA)

DONA‐Approved Doula Trainer

Independent Practice of Childbirth Education and Labor Support, USA


contributions by

Wendy Gordon, LM, CPM, MPH
Suzy Myers, LM, CPM, MPH
Gail Tully, BS, CPM, CD(DONA)


Illustrated by Shanna dela Cruz and Dolly Sundstrom









We dedicate this book to childbearing women, their partners, and their caregivers in the hope that some of our suggestions will reduce the likelihood of cesarean delivery for dystocia; also to the wise, patient, and observant midwives, nurses, doulas, family doctors, and obstetricians whose actions and writings have inspired and taught us.


We have been helped in writing this book by many wonderful people, especially:

  • John Carroll, Alicia Huntley, Shauna Leinbach, Jenn McAllister, Sara Wickham, for reviewing parts of previous editions and giving us useful feedback.
  • Diony Young, for her assistance and support.
  • Anne Frye, midwife and author of Holistic Midwifery, for her stimulating conversation, generous sharing of ideas, and feedback on Chapters 3 and 4.
  • Shanna dela Cruz, our dedicated and meticulous illustrator, and Dolly Sundstrom, who added some new illustrations for this edition.
  • The mother and child depicted in the cover photo.
  • The women and men who posed for our illustrations, including Robin Block, Asela Calhoun, Valerie Catton, Vic dela Cruz, Helen Vella Dentice, Carissa and Zsolt Farkas, Bob Meidl, and Lori Meidl Zahorodney, Katie Rohs, Maureen Wahhab, Celia Scouten, Susan Steffes, and class members in Penny Simkin’s childbirth classes, staff members of Waukesha Memorial Hospital, Aurora Sinai Hospital, and St Mary’s Hospital of Milwaukee, Wisconsin, USA, and the Medical Librarians at the Northridge Hospital in Northridge, California, USA.
  • Celia Bannenberg, for permission to redraw the deBy birthing stool.
  • Jan Dowers, Lesley James, Tracy Sachtjen, and Heather Snookal, Tanya Baer, Candace Halverson, and Molly Kirkpatrick, who provided support and assistance with manuscript preparation of previous editions.
  • Leona VandeVusse PhD, CNM, and Dolly Sundstrom CD, for extensive editorial and reference assistance.
  • Marvis Schorn PhD, CNM, FACNM for expert review of third‐stage labor material.
  • Ann Neal and Kimberly Belanger for their stimulating conversations regarding the content of the Labor Progress Handbook.
  • Our patient and highly competent editor, Robert Hine.
  • Special acknowledgment to Kathy Wilson and Katie Rohs, who were extraordinary doulas to Penny Simkin through the preparation of this edition.
  • Last but not least, we wish to acknowledge our families who have helped us in countless ways as we devoted ourselves to this larger than expected task.

Foreword to the Fourth Edition

Traveling to many parts of the world in my role as President of the Royal College of Midwives over the last few years, particularly countries where the normal birth rate is lowest and the cesarean section rate is highest, I have been struck by the efforts being made to make a straightforward and healthy vaginal birth a possibility, in an apparent vacuum of expertise, understanding, and knowledge. Many want to know how to set up services where normal birth is a possibility. Many want to know how to support women through labor, enhancing the possibility of success, but recognizing when intervention is necessary, and also give a positive experience.

The Labor Progress Handbook, first published in 2000 and now in its fourth edition, is crucial and unique to this work. It is a source of knowledge that will be critical to filling the vacuum. Since the first edition was published, the knowledge base and expertise has grown exponentially. We are more aware than ever of that delicate balance of physiological and psychological processes that are so fundamental to the outcomes of birth (no matter what is the route of birth). There is growing awareness of the neurophysiological effects not only on health of pregnancy and progress of labor, but also relationships, especially between mother and baby, and long‐term wellbeing, of this balance.

At the same time, frustratingly, the cesarean section rate continues to rise or the rate is intractable even where there is a commitment to bringing it down. Normal birth rates, however we define normal birth, are falling. Even in the United Kingdom, with a strong midwifery profession, the normal birth rate is low and the cesarean section rate is currently over 25%. We need not only a commitment to enabling normal birth, but also to know how to support it.

This fourth edition of the Handbook is a unique and critical resource of this knowledge and understanding. It is crucial to knowing how we might provide a safe and positive experience. The Labor Progress Handbook (4th edition) strikes at the most challenging issue we face as we try to increase rates of normal birth—how to recognize, support, and enhance progress in labor. Everyone concerned with the care of women, their babies, and the family during pregnancy and birth—midwives, doctors, nurses, doulas, childbirth educators, companions, all birth workers—will find the book brimming not only with evidence, skills, anatomy and physiology, step‐by‐step instructions, and clear diagrams, but also a holistic approach that recognizes and explains the delicate neurohormonal physiology, the connection between body and mind, and the effect of fear and emotions, the impact of environment, and the importance of comfort, reassurance, and support.

The Labor Progress Handbook (4th edition) is not only for those newly entering the field; novices and experts alike will all gain from the concise but rich format, accessibility of information, and reconsideration of approaches and knowledge that are changing rapidly. Every one of us will be made to think and reconsider.

The holistic comprehensive approach is crucial, not only because a number of complex factors will affect the outcome of pregnancy and birth, but because a positive experience is crucial, no matter what the outcome. This comprehensive approach has a strong basis in evidence. To convey this complex evidence, not only summarized and applied but also evaluated, in such a readable form in such a compact book, is a remarkable achievement.

One of the really important aspects is the recognition that birth workers do not always work in ideal environments, and routine practices are not always evidence based. As understanding and ideas change so rapidly, few of us practice in ideal circumstances. While the book gives enough ammunition to challenge practices and approaches that may not be helpful and may be harmful, many will need to provide day‐to‐day care in settings that make support for labor progress more difficult. For example, rates of epidural anesthesia are very high in many parts of the world, and so one of the important changes in this new edition is a chapter on how to maintain progress when there is an epidural.

Since the first edition in 2000, knowledge and awareness of the extent to which birth might be traumatic has risen. There is more information on trauma‐informed care in this new edition.

Every birth worker should use and carry this book. The “Toolkits” (the last two chapters) are of huge real‐time use, and are designed for quick reference to deal with specific problems with slow progress or pain in labor.

One of the major indications for cesarean section performed in labor is dystocia. As we emerge from a world where in the affluent economies cesarean section has been performed almost routinely, we have lost the ability to assess progress of labor, to support progress while providing comfort and security to the laboring woman. Many managing the problems of long latent phase or prelabor, or prolonged labor, need help in managing the woman’s care safely and humanely.

Now, as we seek to avoid cesarean section, particularly the first or primary c/s, The Labor Progress Handbook (4th edition) will be central to our work. Neither must we forget parts of the world where c/s and assisted birth is not easily accessible. The information contained here will be useful and important to the development of skilled birth attendants in less affluent parts of the world.

Now enjoy, read through, thumb through, look up, reread, test your skills and knowledge, carry in your pocket. Whether you are novice or expert you will find understanding, knowledge, instructions, and the inspiration to find ways to help labor progress to healthy, safe, and joyful birth, and where that progress has not been possible, to know that your care has been of the best.

Lesley Page CBE
PhD, MSc, BA, RM, RN, Honorary DSc, HFRCM
President Royal College of Midwives UK
Visiting Professor in Midwifery, King’s College London UK, and Adjunct Professor of Midwifery, University of Technology Sydney and Griffith University Australia