The Third Stage
The third stage starts when your baby is born and is complete when you birth your placenta. There are two primary ways you can choose to manage your third stage – physiological and active. Many facilities offer a modified active third stage.
Physiological third stage
Physiological management of the third stage involves you birthing your placenta with observation but no medical intervention. Your uterus needs to continue to contract down to push the placenta off the wall and into a position where you feel ready to push it out. Sometimes it will come without you needing to push.
Your contractions usually die off a little directly after baby’s birth. The contractions stop because the primary stimulus for contractions (i.e. your baby) is already out. However, your contractions can be restarted by having skin to skin time with your baby and putting your baby to the breast. These actions stimulate the release of oxytocin – the same hormone responsible for your contractions.
Oxytocin also acts after your baby is born as the bonding hormone, and is responsible for your letdown reflex when breastfeeding. If the baby is sleepy or not interested in feeding just yet, stimulating your nipples while your baby remains skin to skin can work well. These contractions help your uterus to push out the placenta and the membranes.
If you are choosing to cut the cord and disconnect baby from his placenta, it will be ready to cut when the cord stops pulsating.
Active management
Active management of your third stage involves your consent to an oxytocin injection and controlled cord traction (CCT) to remove your placenta. The hormone is usually given in the leg when your baby is born. After this, the cord is clamped and cut straight away. The doctor or midwife will support your uterus, pull gently on the umbilical cord and help you birth your placenta.
Modified active third stage
An active third stage can be modified to include delayed cord clamping. If you wish to manage the birth of your placenta this way, you still require the hormone injection. However, the cord is not cut until it stops pulsing. After this, the midwife or doctor will continue as they would if you were to have had an active third stage.
After you birth your placenta, your midwife or doctor will feel your tummy to ensure your uterus contracts down. Ideally, it would be sitting about halfway between your pubic bone and belly button. It should feel about the size of an orange and the same firmness.
This examination is important, as your uterus needs clamp shut the blood vessels that supplied your baby with oxygen and nutrients. If your uterus is soft (or ‘boggy’), those blood vessels continue to leak, and you can have an unhealthy volume of blood loss. If this is the case, your midwife will ask your permission to massage it. Your uterus will usually respond by contracting again. This massage can be uncomfortable, even painful. However, it is the lesser of two evils. It may be the difference between average blood loss and post-partum haemorrhage.
Complications
Sometimes complications may occur with the third stage, including:
- Post-partum haemorrhage – Some women will bleed heavily during the third stage. This kind of bleeding is an emergency and needs immediate management.
- Retained placenta – sometimes the placenta does not separate from the uterus. If this happens, your consent will be sought for a small operation to remove it. We will perform this procedure under a regional anaesthetic. However, in the case of an emergency, it may be done under general anaesthetic.
You may want to research the management of your third stage during your pregnancy and include it in your birth plan. If you have yet to indicate your wishes, you may do so during labour.
After you birth your placenta, we will ask you permission to check your perineum to see if there are any repairs needed. Click here for more information on needing stitches.
If you have had problems in the first or second stages of your labour, or you have had a problem with a previous birth, a physiological third stage may not be a safe option for you. Please discuss this with your health care providers during your pregnancy.
For more information about the third stage of labour, please click here.
Dr Janelle McAlpine (PhD), Clinical Midwife
Photo by zlikovec used under license from Shutterstock.com