The third stage of labor starts after your baby is born and ends with birthing the placenta. Even after your beautiful baby is born your uterus will continue to contract. These contractions are generally more mild than the contractions you experience during birth. As your uterus begins to contract and shrink, your placenta will detach from your uterine wall. The blood vessels are closed off, and the placenta is pushed out. You have many options for what interventions are employed during this stage and whether your care provider uses active or expectant management. This includes the timing of clamping the umbilical cord, medications, and physically pulling on the umbilical cord. This episode explains your choices during the third stage of labor and examines the research to give you the information you need to make an informed decision.

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The Third Stage

The third stage of labor starts after your baby is born and ends with birthing the placenta. Even after your beautiful baby is born, your uterus will continue to contract. These contractions are much more mild than the contractions you experience during birth. As your uterus begins to contract and shrink, your placenta will detach from your uterine wall. The blood vessels are then closed off, and the placenta is pushed out. If you have a cesarean birth, your placenta is removed by your doctor through the incision after your baby is born.

Potential Complications

Your care provider will monitor you closely to ensure everything goes smoothly during the third stage. There are some potential complications that can come up during this process, including postpartum hemorrhage, a retained placenta, and uterine inversion. 

Postpartum Hemorrhage

Some blood loss after birth is normal. Postpartum hemorrhage is excessive bleeding after childbirth, generally defined as blood loss of 500 ml (16.9 oz) or more after a vaginal birth or 1,000 ml or more after a cesarean birth. Postpartum hemorrhage is more common in low-income countries where access to care is limited, but the rates of postpartum hemorrhage have been on the rise in developed countries.

Doctors and midwives estimate the amount of blood loss because they cannot accurately measure it. Care providers can estimate blood loss from the number of soaked pads or by weighing sponges used to soak up blood. Some tests can assist in diagnosing postpartum hemorrhage. These include blood tests of your hematocrit (red blood cell count) or clotting factor, measuring your blood pressure and pulse rate, a pelvic exam, or an ultrasound to identify the source of bleeding.

Postpartum hemorrhage is the number one cause of maternal mortality. Postpartum hemorrhage is most common in the first 24 hours. If you have your baby in a hospital, you will be closely monitored during this time. If you have your baby at home or a birth center, your care provider will be there for several hours following your labor, and although you will be on your own sooner, you should have access to your care provider via phone.

Late or delayed hemorrhage happens between 24 hours following your birth and up to 6 weeks. All of the blood and tissue (lochia) in your uterus must come out. It’s basically like having a period, except that it is much heavier and can last for up to 6 weeks. The heaviest bleeding is in the first few days and should gradually get lighter. You may feel gushes of blood; this can happen when you are breastfeeding because that causes the release of oxytocin, which can make your uterus contract. You may also get a gush of blood when standing up from a sitting or lying position. You could have blood clots, which are like thick chunks of blood. If the clots are bigger than about the size of a golf ball or you are soaking a pad in under an hour, you should call your doctor or midwife. If you have any concerns, please contact your doctor or midwife immediately.

Risk Factors for Postpartum Hemorrhage

Risk factors for postpartum hemorrhage include: 

  • A past postpartum hemorrhage, uterine inversion or rupture, or uterine atony. Uterine atony happens when your uterus doesn’t contract well after you have your baby and is more common with twins or if you have had several children. 
  • Issues with your placenta, like a placental abruption, when it separates from the uterine wall before birth. Placenta accreta is a risk factor when the placenta grows too deeply into the uterine wall. Another risk factor is placenta previa, where the placenta covers part of your cervix. Lastly, a retained placenta increases your risk for hemorrhage, and this is when all or part of the placenta remains in your uterus. 
  • C-section 
  • Labor induction 
  • Perineal tearing or an episiotomy 
  • Blood conditions or infections 
  • Obesity 
  • Preeclampsia 

Warning Signs and Red Flags

Some warning signs of postpartum hemorrhage include blurred vision, chills, feeling like you may faint, feeling weak, nausea, if your skin goes pale, and swelling or pain around your vagina or perineum. If you experience any of these symptoms after birth, contact your doctor immediately or call 911. 

Treating Postpartum Hemorrhage

Treatment for postpartum hemorrhage depends on the cause, the particulars of your situation, and the severity of the blood loss. A care provider will start with the least invasive methods to treat it and gradually increase interventions as necessary. Treatment can include manual massage of your uterus, medications, removing any retained placenta, administering fluids or oxygen, stitching a vaginal tear, packing your uterus with gauze, a special balloon, or sponges, embolization of blood vessels, blood transfusions, and in the most severe cases, a hysterectomy, where your uterus is removed. 

While postpartum hemorrhage is a scary complication, it is not common and affects around 4.3% of births in the United States. The majority of those are managed successfully with good outcomes for mothers.

Retained Placenta and Uterine Inversion

Two additional complications can occur. A retained placenta occurs when the placenta does not detach from the uterine wall. The risks involved with this include hemorrhage and infection. The time your care provider is comfortable waiting for your placenta to be delivered will vary and can range from 30 minutes to 2 hours. A uterine inversion occurs when the placenta does not detach and, as it is pushed out, draws the uterus with it, turning the organ inside out. This is a rare complication. 

Your Two Main Options for the Third Stage

It is a high priority of your doctor or midwife to make sure that your third stage of labor goes smoothly and that the placenta is delivered without complications. You have two main choices when it comes to how to birth your placenta: expectant management or active management. Expectant management, sometimes also called physiological management, is without any interventions, and active management can involve medications and some physical interventions. Advocates of expectant management argue that the natural process your body goes through promotes normal separation and birth of the placenta and minimizes complications. Proponents of an active approach argue that active management is quicker and results in fewer complications. Which is the better approach? We will be diving into all of your options so you can decide which is best for you. 

Expectant Management

Expectant management means that the cord is not clamped early, no medications are administered, and there is no pulling on the umbilical cord. Advocates of this method argue that any interference with the natural cascade of hormones that occurs immediately following birth impacts both you and your baby. In general, mothers who are planning a natural birth opt for expectant management, which is more in line with their ideology on birth. This method assumes that everything is happening as it should and that there are no complications. 

Active Management

Active management usually involves early cord clamping, administration of medication, and gently pulling the umbilical cord. This has become more common in the last few decades, especially in hospitals. 

Mixed Management

Now that we have discussed the two main methods, it is also possible to have a combination of these, sometimes referred to as mixed management, where some, but not all, of the active management methods are employed. An example of mixed management could mean that you delay the clamping of the umbilical cord but then receive medications to aid in the delivery of the placenta. Let’s examine each of your options individually.

Delayed Cord Clamping

When your baby is born, it will still be connected to the placenta via the umbilical cord, and blood will continue to flow between the placenta and your baby for a few minutes. This placental transfusion can give your baby about a fifth of its blood volume at birth. At some point after your baby is born, a clamp is put on the umbilical cord, which stops the blood flow. Typically, the cord is cut immediately after clamping it.

The World Health Organization recommends late cord clamping, approximately 1–3 minutes after birth. The American College of Obstetricians and Gynecologists recommends a delay in umbilical cord clamping for at least 30–60 seconds after birth. Benefits of delayed cord clamping include increased blood volume, reduced need for blood transfusion, decreased incidence of intracranial hemorrhage in preterm infants, and decreased frequency of iron deficiency anemia. In addition, a longer duration of placental transfusion after birth may be beneficial because this blood is enriched with immunoglobulins and stem cells, which provide the potential for improved organ repair and rebuilding after injury from disorders caused by preterm birth.

There is an in-depth episode that examines the research and provides many more details on delayed cord clamping, which you can check out here. Some mothers delay clamping of the umbilical cord for longer than one minute or until the cord stops pulsating. The episode on delayed cord clamping examines your options in more detail. If you are considering cord blood banking, it may be challenging to both delay cord clamping and bank cord blood. If you are considering banking your baby’s cord blood, this episode is a must-listen to.

Third Stage Medications

The medications given during active management of the third stage of labor are classified as uterotonic agents. These drugs increase contractions and can be oral, through an IV, or with a shot. There are four main types of uterotonics: oxytocin, carbetocin, ergot derivatives, and prostaglandins. I don’t want to get too technical talking about these types of drugs, but I do want to give you a brief overview.

Oxytocin is your body’s natural hormone that creates contractions; some uterotonics are a synthetic version of this. Carbetocin may be available to you if you live in the UK and Canada, but as far as I can tell, it is not available in the United States. Ergot derivatives can include Syntometrine,  a combination of oxytocin and ergometrine. Lastly, prostaglandins can include misoprostol, which is marketed under the brand name Cytotec. While these medications do vary, they are all under the umbrella of uterotonics because the aim is the same, which is to increase contractions and birth the placenta quickly. 

Research on Uterotonics

Let’s review a few studies examining the different medication options. A review of six trials involving over 9,300 women compared Syntometrine,  a combination of oxytocin and ergometrine, with Syntocinon, which is oxytocin only. The review found that the combo drug was associated with fewer instances of postpartum hemorrhage but had more side effects, notably vomiting, nausea, and hypertension.

A review of 72 trials involving over 52,000 women examined the use of prostaglandins, specifically misoprostol, which is taken orally. When misoprostol was used compared to no other drugs, it did lower the risk for postpartum hemorrhage and blood transfusions. Compared to other uterotonics, misoprostol had higher rates of severe postpartum hemorrhage and use of additional uterotonics but fewer blood transfusions. The review also found that misoprostol is associated with significant increases in shivering and fever compared with both placebo and other uterotonics. The review found that, overall, misoprostol is not as effective as oxytocin, and it has more side effects.

In areas where access to medical care is limited, oral medication, like misoprostol, may have more applications. Postpartum hemorrhage is more common in low-income countries, and it is a priority to find solutions in areas where women may be giving birth with limited resources, in remote areas away from a hospital, and where they may not have access to trained medical professionals. 

A review that included 24 trials involving over 10,000 women found that oxytocin when compared to no uterotonics or a placebo, did reduce the rates of postpartum hemorrhage. Still, the quality of this evidence was low. It also found there may be no difference in needing a blood transfusion and that oxytocin may be associated with an increased risk of a third stage greater than 30 minutes. Compared to ergot alkaloids, it is uncertain if oxytocin reduces the likelihood of blood loss greater than 500 ml. Oxytocin may increase the risk of a prolonged third stage compared to ergot alkaloids, although whether this translates into an increased risk of manual placental removal is uncertain.

If you are planning to have a uterotonic administered during the third stage of labor, it may be helpful to discuss your options with your care provider and talk about the risks and benefits of the different medications available. All of these drugs do differ, and the risks and benefits will vary slightly depending on your situation. Quite a few studies are comparing one drug to another, so when you determine your options, you can look further into specific studies on those. You can also ask your doctor or midwife why they recommend one medication over another. 

Controlled Cord Traction

Another element of active management is controlled cord traction. After your placenta has detached from the uterine wall your care provider can apply traction to the umbilical cord by gently pulling it to assist in the delivery of the placenta. They may also put pressure on your uterus to help it contract. This is sometimes referred to as fundal pressure. Fundus refers to the top of your uterus. There is a method to controlled cord traction, and any care provider performing this intervention should be skilled in the technique. It could be helpful to ask your care provider whether they prefer to apply traction to the cord and their routine procedure. 

Research on Controlled Cord Traction

Cochrane Review focused on controlled cord traction and found no difference in the risk of blood loss over 1000 ml but that it did reduce blood loss of more than 500 ml. There were no clear differences in using additional uterotonics, blood transfusion, maternal death, operative procedures, or maternal satisfaction.

Research on Expectant vs. Active Management

The majority of studies on active management focus on specific drugs. Many of these studies are funded by pharmaceutical companies, who have a vested interest in research outcomes. Research can be costly and time-intensive. I did find an interesting review that was solely focused on active versus expectant management. A review of seven studies involving over 8,000 women found that active management of the third stage reduced the risk of hemorrhage greater than 1000 ml at the time of birth, but adverse effects were identified. The review concluded that given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management.

Using the B.R.A.I.N. Acronym

The BRAIN acronym is one of the most versatile tools for any birth intervention. This tool may assist you as you explore your options for the third stage of labor. Each word in this acronym is the key to a question you can ask to help you figure out whether any intervention or procedure is the right choice for you and your baby. 

  • Benefits: What are the benefits? 
  • Risks: What are the risks? 
  • Alternatives: What are the alternatives? 
  • Intuition: What does your gut or intuition tell you? 
  • Nothing: What happens if you do nothing? 

The power of asking the questions in the BRAIN acronym is asking all five. While each is helpful, they cover every aspect of the pros and cons together.

Talk to Your Doctor or Midwife

When exploring what methods you want to use or avoid during the third stage of labor, talk to your doctor or midwife about their policy and recommendation. From there, you can discuss your options and any concerns to figure out what route you want to take. Some professionals or hospitals may have policies requiring interventions during the third stage. If you are requesting to go against a policy of your care provider or birth venue, prepare for pushback. The best way to work through any differences in preferences and policies is to talk to your doctor or midwife.

Including Your Preferences in Your Birth Plan 

Creating a birth plan is an excellent exercise to clarify the interventions you want to include or avoid. A birth plan is your plan of how you envision your birth and what happens directly following the birth of your baby. This is much more than a piece of paper you hand to your care provider. It is the process you go through to prepare for your desired birth experience. This process will lay the foundation for preparing for the scenario in which everything goes as planned and what should happen if things do not. The value of a birth plan has a lot more to do with the process of creating it than it does with the finished product. 

The Pregnancy Podcast has several resources to help you create your birth plan: 

In Summary

Remember that you have a lot of options here. The three main interventions used in active management are early cord clamping, uterotonic medications, and controlled cord traction. While it is easy to break this down into two camps, expectant and active management, you can also choose a mixed approach. It is possible to opt into one, two, or three of the procedures or out of all. Please speak with your doctor or midwife to assist you in deciding what the best course of action is. 

Keep in mind that as your birth unfolds, there is always the possibility that your plans need to change to accommodate complications or circumstances that arise. Thankfully, you will work with a skilled medical professional, and your doctor or midwife can navigate the best course of action to ensure a safe third stage.

Thank you to the amazing companies that have supported this episode.

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