The third stage of labour is the delivery of the placenta- the baby’s life-support system that has supplied your baby with oxygen and nutrients, and taken waste products away. After the baby is born, contractions resume after a few minutes, but at a much lesser intensity (although they can be more noticeable if you’ve had a baby before). These contractions cause the placenta to peel away from the wall of the uterus and the placenta, with the membranes of the empty bag of waters and cord attached, will pass down and out of your vagina. Your midwife will carefully examine the placenta and membranes to make sure that nothing has been left behind. You may also like to have a look at the placenta that has supported your baby throughout the pregnancy. The midwife will also feel your tummy to check that your uterus is contracting well in order to help stop the bleeding from the place where the placenta was attached. Delivering the placenta can take anything from a few minutes to up to an hour and can depend on whether you have an actively managed or natural third stage.
For most women and their labour partners, third stage is a lot less interesting than the other stages of labour. But it is part and parcel of the whole process, and sometimes things happen in the third stage that can affect the nature of the whole labour experience, so it’s worth thinking about. Some things you might like to consider are whether to have a natural or managed third stage, and if you would like to wait for the cord to stop pulsating before cutting it. Whether you plan to give birth at home or in hospital, it is up to you what you choose to do.
Active Management
‘Active management’, or a ‘managed third stage’, means that you have an injection as the baby is born, or shortly after, which makes your uterus contract strongly to push the placenta out quickly, and then makes it clamp down to reduce bleeding after the placenta is delivered. In the UK, the drug most often used is Syntometrine – a combination of Syntocinon, to bring on strong contractions, and Ergometrine, to make the uterus clamp down hard afterwards.
The advantages of an actively managed third stage are that the third stage is usually over quickly, and average blood loss is lower. The mother does not usually have to ‘do’ anything – she just waits, while the drugs and the midwives do the work (the midwife will usually pull on the cord to get the placenta out). This can mean that there can be a lot of activity involved if you do have the injection, so you might want to take this into consideration if you would prefer to have time with your baby without any distractions immediately after he’s born.
The disadvantages of an actively managed third stage for the mother are that some women feel sick, dizzy or faint or have a headache after being given the drug, and some vomit and are unable to hold their baby for a while after birth because they feel unwell. Estimates of the proportion of mothers affected by these symptoms vary from 1 in 8 to 1 in 3, so while the majority of mothers will feel fine after being given Syntometrine, the risk of ‘minor’ side-effects should not be ignored. It can cause a rise in blood pressure for some women and there is thought to be a higher risk of trapped (retained) placenta, where the placenta is stuck inside the uterus. If a trapped placenta occurs, it usually has to be manually removed in an operating theatre.
Natural third stage
A natural, or ‘physiological’ third stage, means that drugs are not automatically given to deliver the placenta, but that the woman waits for it to arrive naturally. While she is waiting, her midwives should observe her carefully and, if she needs it, she could be given advice on techniques to help her push the placenta out. For instance, some women find that if they push as if they were trying to do a poo (bowel movement), the placenta rapidly appears. Some midwives recommend that women blow into a bottle to help push the placenta out.
If, at any stage, the woman’s blood loss worries her or her midwives, she still has the option of having drugs to push out the placenta and control bleeding. The downside of a ‘natural’ third stage is that it can take longer to deliver the placenta, on average, and that average blood loss can be slightly higher. It is quite normal for a natural third stage to take half an hour or an hour or more, although ten minutes is also perfectly common. The mother has to be actively involved in the birth of her placenta; she must push it out herself, and sometimes this involves moving around, and trying different positions and techniques, although often, it takes no more than standing up as the placenta slips out. Your baby can be close to you while you are doing this, and for many women a physiological third stage means no more than sitting down,and cuddling the baby for ten minutes or so until she feels the urge to push the placenta out.
If you do not have drugs to aid delivery of the placenta, you can choose to either have the cord cut when it has stopped pulsating (if having a natural third stage, the cord shouldn’t be cut before the cord has finished pulsating), or to wait until the placenta is delivered. This last choice is great for having close bonding time with your baby straight after birth, rather than having him whisked off to be weighed and measured while you get on with delivering the placenta. Seeing and handling your baby, and offering him or her the breast will also stimulate hormones that help the placenta to separate. On the other hand, some women feel they can’t concentrate on delivering the placenta while still attached to their baby. There is some speculation that leaving the cord uncut until the placenta is delivered might somehow help speed up the delivery of the placenta, but there doesn’t seem to be any strong evidence for or against this.
If you’d prefer not to have the injection, it’s a good idea to say so on your birth plan so that the midwife knows in advance.
Cord Clamping
Active management can have drawbacks for the baby if the cord is clamped before it has ceased pulsating. It is not necessary for Syntometrine to be given this quickly, but usual practice in the UK is to give the injection immediately after the birth. The cord is usually clamped before the injection is given, because of theoretical concerns about a powerful shunt of blood from the induced contractions causing the baby getting too much blood, which could lead to severe jaundice.
The downside of early cord clamping is that the baby does not get the benefit of the oxygen-rich blood in the cord and placenta which would come to it in a natural third stage. This is now known to increase the baby’s risk of becoming anaemic in infancy. Moreover, the oxygenated blood in the cord and placenta would normally tide the baby over for the few minutes after birth while the cord pulsated, providing extra oxygen while the baby established breathing. Much of the research on cord clamping is fairly recent and practices in obstetrics are only just starting to change.
It is now being questioned whether early clamping is indeed necessary after an injection of syntometrine, but as early clamping is currently standard practice, you may find that your caregivers are either not up to date with the latest research, or disagree with it. This is changing rapidly in the care of premature babies though, as they are at particular risk of anaemia and benefit significantly if there is a delay before clamping the cord, and is starting to filter through to the mainstream.
If you don’t wish the cord to be clamped until the cord has stopped pulsating, let your midwife know before you’ve given birth, as there isn’t usually much time to discuss things like this after your baby has been born.
