Info Centre - Third stage of labour

Most women don’t know that they have a choice when it comes to the delivery of the placenta, because it has become usual in hospital for women to have a ‘medically-managed’ third stage of labour. But there is another option as this page explains.

The third stage of labour

While defining labour in terms of three separate stages may be helpful, there is a danger that you can lose sight of the fact that all the stages are inter-related and combine to form a whole. How your baby’s birth unfolds has an affect on the relationship between you are your baby, and how you feel about yourself. This holds true for the third stage as much as any other part of the process, and any approach should be as respectful as possible.

‘Active’, or medical, management has become the most common way of dealing with the third stage of labour, ever since it was introduced as a precaution against losing too much blood after birth. If you have had any medical intervention, such as a drip to speed up your labour, you will be given a managed third stage, because there is a risk of bleeding. However, this medically-managed way of dealing with the delivery of the placenta has become so much the norm that most women don’t realise that for those judged to be at low risk of blood loss, there is another, more natural, way of doing it.

Natural delivery of the placenta

The third stage of labour is not just about getting rid of the redundant placenta. This is the time when your baby begins to adapt to life outside your womb and leaving the delivery of your placenta to nature is an integral part in this process.

After birth, the umbilical cord is left intact; it is normally just long enough for you to hold your baby. Helped by a final boost of blood from the placenta, she will take her first breath, then another, and another. As your baby’s lungs expand, her heart and circulation will make the delicate adjustments necessary for independent life. Slowly, the flow of blood from the placenta will decrease, its job nearly over.

Having your baby enclosed in your arms for the first time is a very special moment for you and your baby. As you cuddle her skin-to-skin, your system will be flooded with oxytocin, the hormone of love and labour. This same hormone will soon cause your uterus to contract, expel your placenta, and start the flow of milk from your breasts.

Cutting the cord

After a while, you may sense instinctively that it is time to cut the cord, which will by then have stopped pulsating. Your midwife will first put two clamps in place, then she, you, or your partner can cut inbetween. You will then probably want to spend time holding and admiring your baby. The room should be kept dim and quiet. It’s important that you do not feel tense or watched, or adrenalin may interfere with the natural flow of events. Your midwife should stay close. If you wish, she may examine your perineum to see if you need stitches; she may even do these quickly for you while you are waiting for the placenta.

Your final contractions

After a short time (ten to 15 minutes), you should feel your placenta in your vagina and will push it out with a few small contractions. Your midwife will collect it in a container and place a hand on your belly to check that your uterus is well-contracted. There will be some blood loss at this stage and your midwife will know whether or not the amount is normal.

Medical delivery of the placenta

Active, or medical, management of the third stage involves various procedures aimed at reducing blood loss and preventing possible problems with the delivery of the placenta. It generally involves a combination of three factors and the process normally takes about four to seven minutes. These three factors are:

Administering a drug to the mother as the baby is being born
Early clamping of the baby’s cord, usually immediately after the birth
Controlled gentle pulling of the cord.

Although these three elements are common, there are different ways that the medical delivery of the third stage can be undertaken.

Different drugs may be used

There are a number of drugs that can be used for a medical delivery of the placenta. However, oxytocin and syntometrine are the two drugs most commonly used in the UK. Oxytocin can be given either by an injection into the muscle, or by a drip into a vein via a canula inserted into the back of the hand. Syntometrine is a combination of syntocinon and ergometrine and is given by injection into the muscle. It was thought that the combination of these two drugs gave a stronger more sustained contraction. The drug can be given when the baby’s head is crowning, with the birth of the baby’s shoulder, or after the birth. In the UK, the drug is usually given before the birth so that it can begin to take effect sooner.

Clamping the cord

With medical management of the third stage the cord is normally clamped immediately after the birth of the baby, usually within 30 seconds, and before it stop pulsating. The earlier the cord is clamped the less blood will pass from the placenta to the baby by placental transfusion. However, there is also something known as delayed active management, when a drug is not given to the mother until the cord has finished pulsating and been clamped and cut.

Controlled cord traction

Your midwife will wait for a few minutes for signs that your placenta has separated. She will then gently draw on the cord to extract the placenta, while maintaining a counter pressure on your uterus with her other hand.

Natural or medical – which way is best?

Medical management of the third stage has two proposed advantages. Firstly, with medical management, you’re less likely to lose a significant amount of blood (which means upwards of 500ml/approximately 1 pint). Secondly, it is faster; an average of eight minutes against an average of 15 minutes for a natural third stage – although at this point you will probably be focusing on your new baby and unaware of the time.

The issue of blood loss may sound alarming, and in a small number of women, it is. However, normal blood loss needs to be put into context in that during pregnancy your blood volume has increased significantly. A healthy pregnant women, therefore, has a reasonable amount of blood to spare after birth. You should be aware though that women can unexpectedly lose large amounts of blood during or after the delivery of the placenta. These women need immediate treatment with drugs to control this abnormal excessive bleeding.

Some midwives think that the emphasis on blood loss at the time of the delivery of the placenta may be misleading, believing that women who had a medical third stage may actually lose the same amount of blood overall – but they lose more blood in the few weeks following the birth than women who have a natural third stage.

Possible contraindications for a natural third stage

For some women, there are health risks if they decide to have a natural third stage and for them, medical management has a significant role to play in their care.

Those who cannot afford to lose even a moderate amount of blood in childbirth are: very anaemic women; the malnourished; the unwell or weak; those who have bled heavily during pregnancy.
Those women who are already at greater risk of an above-average blood loss, and may benefit from the ‘protection’ of a medical third stage are: those having twins or very large babies, women with blood disorders, women who have previously had third-stage problems.
Finally, there is a group of women who may be steered toward medical management because the type of labour they have had may mean that the uterus does not work so effectively to expel the placenta and control bleeding. For example: women who have had very long and exhausting labours, those who have had very rapid labours (less than an hour), labours that have been started or speeded up with syntocinon, labours where the woman has chosen to have pethidine or an epidural.

Consider all your options beforehand

Research shows that women often know little about the third stage of labour. As the issues are complex, you should talk about the third stage with a midwife during your pregnancy and receive full and balanced information. You should not be expected to consider natural versus medical management of the third stage for the first time during labour. All things being equal, you should have been able to consider the options and what you decide depends on your circumstances. Talk it over with your midwife.

Page lasted updated 2007.