Third Stage Management – Delivering your Placenta
What is the third stage of labour?
In medical terms, the ‘third stage of labour’, or simply ‘third stage’, describes the time from the birth of the baby until the placenta is delivered.
FYI – the first stage is the cervical dilation phase; second stage is after full dilation, i.e. during pushing.
However, third stage is much more than just a medical event. It represents the time just after your baby has been born, when your baby is transitioning to life in the outside world. As in labour, your pituitary gland is releasing the hormone oxytocin which causes your uterus to contracting, and thus expel the placenta in a similar process to birthing the baby. Just like the first and second stages of labour, this process is best facilitated by an environment that is quiet and peaceful. Additionally, oxytocin increases in response to being close to your baby (especially when there is skin-to-skin contact). Conversely, adrenaline-filled atmospheres can slow oxytocin production.
Why do I need to think about the third stage while I am pregnant?
The third stage, and shortly after, is when the potential for bleeding is the highest. In the broader world, postpartum hemorrhage (PPH) is still the leading cause of death for the childbearing person. While rates of catastrophic postpartum hemorrhage in Canada are low, PPH can still have serious consequences, including the need for further medical intervention.
Short term consequences of PPH
- Administration of emergency drugs
- IV fluids
- Separating you from your baby during emergency intervention
- Manual removal of the placenta
- Blood transfusion
- Increased hospital stay, possible ICU admission
- In extreme cases, hysterectomy
- PTSD for mothers, support people
Longer term consequences of PPH
The longer term side-effect of PPH is anemia. The complications of being anemic postpartum include:
- Extreme exhaustion, beyond normal postpartum expectations
- Slow milk production as the body’s resources go into producing blood cells
- Interference with bonding due to extreme exhaustion
- Increased susceptibility to infection
- Constipation from taking iron supplements
- Increased chance of postpartum depression
Are there risk factors that increase the chance of PPH?
Pre-existing medical factors
- Bleeding disorder, uterine fibroids >5cms, hypertension
Previous pregnancy history
- Previous PPH, previous retained placenta
- High blood pressure
Anything that especially stretches the uterus
- Large baby (>4kgs or 9lbs), polyhydramnios (extreme amount of amniotic fluid), twins
- Prolonged labor
- Prolonged pushing stage
- Prolonged third stage (>30 minutes)
- Full bladder
- Uterine infection
- Shoulder dystocia
Mode of delivery
- Forceps, vacuum, cesarean section
Are there any ways to minimize the chance of PPH?
Before the placenta
Delivering the placenta as quickly as possible has also been shown to decrease the chance of PPH. This can often be done by the mother pushing during uterine contractions (by this point they feel more like cramps than like labor contractions). In combination with the mother’s efforts, the careprovider may choose to use careful traction on the umbilical cord to ease the placenta out.
If you have any risk factors (pre-existing or arising during labor), then it would be recommended to use an ACTIVE MANAGEMENT of third stage approach. This would involve giving you a prophylactic shot of synthetic oxytocin in your thigh as your baby is being born, and then using cord traction as soon as there are clinical signs of the placenta starting to deliver. Active Management to prevent PPH has become the default standard of care in many places including most hospitals.
If you have no pre-existing risk factors and have had a straightforward labour of average time with no drugs or interventions, it would be fair to assume that your body will be able to keep producing enough oxytocin to complete the third stage of labor efficiently. In this case you will be offered the choice of using a PHYSIOLOGICAL MANAGEMENT approach of this stage. Generally, this is a more hands-off style. Research shows that for low-risk mothers and careproviders with appropriate training and experience, the judicious use of this approach can be the most effective option to minimize bleeding.
Most placentas are delivered within 10-15 minutes, and almost all by 30 minutes. For this reason, if your placenta is not out after 30 minutes of Physiological management, it would then be recommended to switch to an Active approach, starting with giving you an injection of oxytocin.
After the placenta
Whether you have a Physiological or Active approach to third stage, once the placenta is out, promoting efficient contraction of the uterus will minimize bleeding. Your nurse or midwife will gently feel your abdomen as soon as the placenta is out to assess whether the uterus is tightly contracted. If not, this can be promoted by massaging or rubbing the uterus from on top of your abdomen.
If at any time you are bleeding significantly, you should prepared for your careproviders to act quickly to perform various medical procedures including giving emergency drugs.
If I choose Active Management, does this mean the cord will be cut right away?
Immediate clamping of the umbilical cord used to be part of Active Management but has not been shown to be effective in minimizing blood loss. Because of this, and because there are other useful reasons to not clamp the cord immediately, your baby’s cord will be left intact until it has stopped pulsing UNLESS the baby needs to be resuscitated and this cannot be done with the cord intact OR you are actively hemorrhaging and emergency measures are hampered by having the baby still attached.
Considerations in third stage management
- Less pain from the oxytocin injection when given at the moment of birth: you likely won’t even know you had it, unlike if given a few minutes later when you will very much feel this uncomfortable injection.
- Careproviders tend to be more experienced in this style of management
- Less likely to experience the most common side effect of oxytocin which is uterine cramping. Not all people experience this, but sometimes it can be severe and require pharmaceutical pain meds to cope.
- Less risk of jaundice in the newborn
- Less risk of delayed PPH (2 or more hours after the birth), which can potentially happen after the synthetic oxytocin wears off
If you develop risk factors in labour, it’s not too late to choose to Active Management. In fact, your careprovider is likely to recommend this.