Close up of a fresh human placentaDelivering your placenta: The third stage of labour

When your midwife or doctor talks about the third stage of labour they are referring to the time from your baby’s birth until the placenta and membranes, and the remaining section of umbilical cord attached to them, have been delivered. On average, the third stage of labour lasts for between five and 15 minutes. There are two methods that can be used to deliver the placenta and membranes:

 

  • ‘Active management of the third stage’
  •  ‘Physiological (or natural) third stage’.

Your midwife or doctor will discuss both of these methods with you and the benefits and disadvantages associated with each in helping you to choose the right method for you and your baby. There can be circumstances however, where your health professional may recommend one method over the other, or where the type of birth you have determines how your placenta is delivered. For instance, if your baby is born by caesarean section then your placenta will need to be delivered using active management of the third stage. See also our articles on ‘Caesarean section birth’; Vaginal Birth after Caesarean (VBAC)’ and ‘Forceps & Ventouse Births’.

 

Delayed clamping of the umbilical cord

Women with uncomplicated pregnancies who achieve a normal vaginal birth may also choose a more natural approach, without the use of drugs, for the delivery of their placenta and membranes. Some women request to have clamping and cutting of the cord delayed by five minutes or longer until the cord has stopped pulsating – this usually happens spontaneously 5-20 minutes post birth. Studies show that delayed clamping of the umbilical cord in term babies, for at least two minutes post birth, improves babies’ haemoglobin levels (iron count) and reduces the risk of anaemia. The blood also helps to fill the blood vessels around the baby’s lungs and helps them to breathe independently outside their mother’s womb. Where women give birth to a preterm (premature) baby and the baby is born in a good condition, delayed cord clamping may also be undertaken to allow more blood to naturally flow into the baby from their placenta.

 

Physiological Third Stage of Labour

Women with uncomplicated pregnancies may choose to have clamping and cutting of the cord omitted altogether in favour of having a Physiological (or natural) third stage. Having a physiological third stage allows the mother to hold her newborn baby skin-to-skin while the baby is still attached to its umbilical cord and the placenta. The cord is allowed to stop pulsating in its own time, without any intervention or administration of drugs ie Syntometrine or Syntocinon.

As the uterus contracts post birth the fundus moves higher and becomes more rounded in shape; the area of the uterine wall where the placenta is attached shrinks in size which causes the placenta to shear off/separate away from the uterine cavity. When this happens, there may be a sudden gush of blood and the remaining section of the umbilical cord can be seen to lengthen, as the placenta drops into the lower part of the uterus and is pushed into the vagina. Women may often report feeling the sensation of fullness in their vagina when this happens. Some women will have a spontaneous urge to push the placenta out, whilst others find that by simply adjusting their position eg sitting in a more upright position, allows the placenta to simply slide out.

ChildbirthCompared with active management of the third stage, having a physiological third stage tends to take longer – anything between 10 min and one hour. This can seem like rather a long time to have to wait for the last stage of labour to be completed; however, you will be encouraged to hold your baby in unhurried skin-to-skin contact after they’ve been born and this precious time gives you an opportunity to welcome and meet your new baby! Offering your baby a breastfeed as soon after the birth as they are ready to feed, will also help to encourage the uterus to contract down and aid placental separation. See also our article, ‘Breastfeeding’.

Studies have found that women who have a physiological third stage of labour have a slightly increased risk of losing more blood immediately after the birth. Therefore, if you are known to be anaemic or have a blood clotting disorder; your midwife/doctor is likely to recommend that you have active management rather than a physiological third stage. Physiological third stage is also contraindicated in women who have had previous third stage problems such as retained placenta or post partum haemorrhage (PPH) and in those expecting twins, triplets or more, or are expected to give birth to a very large baby. This is because these women are at increased risk of heavy bleeding. See also our article, ‘Anaemia after childbirth’.

 

Active Management of the Third Stage

new born infant in the operation roomActive management of the third stage of labour has been favoured by doctors and midwives for decades. This involves the early clamping and cutting of the umbilical cord, injecting an oxytocic drug – Syntometrine or Syntocinon into the top of the woman’s leg (to make the uterus contract), and delivering the placenta by controlled cord traction (CCT). Clamping of the cord can be undertaken as early as one minute post birth, or even sooner with studies showing that this procedure is frequently undertaken within 10-30 seconds of the baby’s birth. Immediate clamping/cutting of the cord will be undertaken in obstetric emergencies and some preterm births where the baby is born in poor condition and needs resuscitation (assistance with breathing) without delay.

Where a woman has had a complicated labour, where her contractions have needed to be augmented (made stronger, regular and more effective) with a syntocinon infusion (drip), and/or has needed assistance to birth their baby using forceps or the ventouse; the midwife/doctor will always recommend active management of the third stage. This is because there is an increased risk of having heavier bleeding following long and complicated labours and births, as the uterus often becomes tired and contracts less effectively to expel the placenta. This can increase the risk of postpartum haemorrhage.

The injection of syntometrine is given into the woman’s thigh as her baby’s shoulders are being born, or immediately after the birth. Most women aren’t even aware that the injection has been given because there is so much happening at this time. Once the baby has been safely delivered onto the mother’s abdomen (unless she requests otherwise); the midwife/doctor feels the woman’s fundus (top of the uterus) for the next contraction. They may also watch for signs of the placenta separating from the uterine wall such as a gush of blood and lengthening of the umbilical cord, as previously mentioned. Once a contraction is felt, CCT is performed. This involves the midwife/doctor placing one hand on the women’s lower abdomen and pushing the side of their hand inwards, just above the pubic bone, to guard (support) the uterus, whilst applying a steady downward traction on the umbilical cord to deliver the placenta and membranes. This process is never rushed because it is important to ensure that the placenta and membranes are delivered complete. It isn’t a painful procedure because the placenta and membranes are much smaller and softer than the baby!

Research shows that women who have active management of the third stage are less likely to have a heavy blood loss once the placenta has been delivered. However, there have also been reports that post birth bleeding – lochia continues for longer after active management. See also our articles, ‘Blood loss after your baby’s birth’ and ‘Anaemia after childbirth’. Syntometrine is also known to have side-effects and its administration can cause nausea, vomiting and headache in some women.

 

Retained placenta

In around 3% of births the placenta and membranes do not deliver as they should and some or all of them remain inside the uterus – this is termed ‘retained placenta’. Retained placenta is said to have occurred where the placenta remains in the uterus in excess of one hour post birth. There are three types of retained placenta:

Trapped placenta – where the placenta has separated but is trapped behind a closed cervix

Placenta adherens – where the uterine muscle (myometrium) behind the placenta has failed to contract

Placenta accreta – this is a much rarer condition and refers to the placenta embedding deeply into the myometrium.

 

Managing retained placenta

The midwife/doctor ensures the woman’s bladder is empty, as a full bladder can interfere with the uterus contracting down and expelling the placenta and membranes. A urinary catheter (fine tube) is inserted into the bladder and usually remains in place for 12 hours afterwards. If one has not already been sited, a fine plastic tube called a venflon will be inserted into a vein in the hand, so that an intravenous infusion can be started. A retained placenta will need to be removed by a doctor – this procedure is called manual removal of placenta (MROP) and is performed in the Delivery Suite Operating Theatre under regional anaesthetic (spinal/epidural). For further information on epidurals and spinal anaesthesia, see also our article ‘Pain relief options for labour and birth’.

Having regional anaesthesia means that the woman is completely numb from the waist down and is unable to feel any pain or discomfort during the MROP. During the procedure, the woman’s legs are supported in lithotomy poles (as with forceps and ventouse births) and the doctor carefully manually removes the placenta and any membranes that have been retained inside the uterine cavity. They then check the uterus to ensure it is completely empty. Any perineal trauma (tears) sustained during the baby’s birth will be sutured (stitched) and a strong anti-inflammatory painkiller (Diclofenac suppository) is often given rectally (up the bottom) to ensure the woman remains comfortable once the spinal/epidural has worn off. The doctor will also give the woman intravenous antibiotics to protect against an infection developing in the uterus (uterine infection). Where there is heavy blood loss during or following MROP, some women may need to be given special drugs to make the uterus contract down and curb any further bleeding. The midwives and doctors will continue to monitor the woman’s blood loss and check their blood pressure, temperature, pulse, respiratory (breathing) rate and oxygen saturations, and vaginal bleeding regularly post birth. A MROP can sometimes cause trauma to the genital tract, so any early signs of infection will always be treated promptly.

If you have any queries or concerns we always recommend that you speak to your own midwife or doctor who can provide additional information and support.

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