Lesson 13 explores how we can redefine second stage labor—particularly in water—and shift the provider’s role from managing birth to protecting the physiologic process. With a special focus on preventing and managing shoulder dystocia, this lesson blends positioning, timing, and instinctive maternal effort with clear clinical awareness.

Barbara begins by introducing the importance of the pause between the birth of the head and the birth of the shoulders. In water, this rest period becomes a natural window for assessment and observation. Providers are encouraged to remain hands-off and practice what she calls “masterly inactivity,” staying present without interfering unless truly necessary. This space allows the baby to rotate on their own, and gives the mother time to reconnect with her body’s rhythm.

Throughout the lesson, movement is emphasized as the most effective and gentle intervention. Using the principle “If you want the baby to move, then move the mother,” Barbara outlines a variety of labor positions that dynamically change the shape of the pelvis—such as toe squats, lunges, and shifting between knees and hands. These positions increase pelvic outlet capacity and support fetal descent without force.

A structured tool called the 30-30-30 guideline is introduced as a clinical framework for responding to delayed rotation or suspected shoulder dystocia. The guideline recommends 30 seconds of observation, 30 seconds of movement, and, if needed, 30 more seconds of alternate positioning. Key assessments during this time include fetal heart rate, maternal sensations of movement, micro-rotations of the baby’s head, and pulse checks using the fontanelles or cord.

If the baby still doesn’t rotate or progress, the provider is instructed to calmly support the mother out of the tub. Maneuvers such as McRoberts are never to be performed in water. Instead, the lesson teaches how to quickly transition to the bed while maintaining safety and emotional support for the mother.

Barbara also introduces the concept of pulling instead of pushing—encouraging providers to help the mother redirect effort through core strength and breath, often with tools like a rebozo or supported standing. This method helps synchronize maternal energy with fetal movement and supports the idea of “letting the baby out,” rather than forcing birth.

Best practices for instinctive pushing—such as laboring down and vocalizing through the urge—are presented as alternatives to coached pushing, which can disrupt physiologic rhythm. Videos from both home and hospital settings, including from Dr. Hermann Ponette’s team in Belgium, reinforce these strategies in real-life births.

The lesson concludes by reviewing how upright, vertical positions help align the curve of the pelvis with the spine, supporting a smoother expulsion phase. Final reflections reinforce the lesson’s core message: when we trust birth, support maternal movement, and act only when needed, we create the conditions for a safer and more empowering second stage—especially in water.