Tuesday, June 12, 2012

Active Management of Third Stage

Third Stage

The third stage of labor lasts from when the baby is born to when the placenta is birthed. Once the baby is expelled, the uterus generally continues contracting. Stimulation of the nipples by the baby helps the uterus contract down to pre-pregnancy size. The contractions and the hormones cause the placenta to detach from the uterine wall. The mother may feel another urge to push, but pushing out a squishy placenta is much easier than pushing out another baby!

The third stage generally lasts about an hour. It can last more than that, but generally the hospital won't even wait more than 30 minutes. If the placenta is taking a long time to detach and come out, there is a fear that it is a "retained placenta," and they may manually remove it. If the placenta is retained, or if pieces of it are retained, there is a risk for postpartum hemorrhage (excessive bleeding). This is why 1. the doctor or midwife will check to make sure the placenta is intact, and 2. the doctor or midwife may administer a shot or a bolus of pitocin to get the uterus to continue to contract.

Active Management 

Postpartum hemorrhage is the biggest childbirth complication and maternal killer worldwide. The World Health Organization recommends pitocin for all women to prevent postpartum hemorrhage and maternal mortality. They refer to this as "active management."

Many women want to avoid pitocin, even postpartum, because of it's potential side effects.  Normal expulsion of the placenta is possible without pitocin. We also have the luxury, in the United States, of having immediately available emergency care. If you begin to bleed excessively after birth, either your care provider would notice and take steps to stop it, or you would be able to call 911 and have an ambulance with you in a short time.

If you don't see a problem with receiving pitocin after birth, go for it. It is preventative, and recommended. And if you don't want it but end up needing it because of a suspected retained placenta, don't worry too much about it - it is a life saver in many instances!

The midwife at Midwife's Thinking Blog wants you to know something important:
Physiological placental birth is an option and possible if you manage to avoid induction, augmentation, an epidural or complications – but be aware of how difficult it may be, and don’t beat yourself up if it doesn’t happen.
Some medical interventions can mess with a physiological placental birth because they interrupt your body's natural production of oxytocin (your labor hormone!). Just something to keep in mind, and another bonus to a natural birth. Another thing that interrupts this - stress.

Keeping baby skin to skin and on the breast immediately after birth is a great way to help that placenta out!

In a world where the majority women are having inductions, pain medication, anesthesia, augmentation, and stressful birth environments in the hospital, active management of the third stage might be the best idea for most women. 

Cord Traction

I do have to add here that I don't think cord traction is a good idea. I'm not a doctor or a midwife, but cord traction seems like a terrible idea, yet one that is done ALL THE TIME. This is when the care provider pulls on the umbilical cord to help the placenta out (sometimes in conjunction with the pitocin). This can cause additional problems - a placenta that hasn't separated from the uterus yet can cause a partial detachment (adds to hemorrhage), you can snap the umbilical cord (not a huge deal), or worst case scenario, pull the uterus out!

Even though this is "faster," which doctors like, it doesn't seem to do much good. I really wouldn't want to risk making things worse by pulling on the cord, especially if the third stage hasn't been that long, yet! 

How long did it take for your placenta to come out? What are your thoughts on the active management of the third stage?






  1. I've never seen a third stage last an hour, but it's always the time frame I hear. For my three births my third stages lasted about 10-15 minutes, with only one of them having "help." For the births I've attended as a doula I think the longest I've seen is about 45 minutes with most taking about 10-20.

  2. I think generally it takes less than 45 minutes and augmenting with pitocin can be uncomfortable to painful for a mother who has had an otherwise unmediated birth. With the u medicated and low stress births I've been to its taken less than 15 minutes. Watching a very aggressive physician pull on it made my whole body cringe. I think that's the least advisable way to speed it up (and why does everything need speeding up??) I believe nipple stimulation and abdominal massage if necessary are better first steps. Obviously when hemorrhage is involved go straight to pitocin! I am really not sure why WHO recommends this across the board it seems unnecessary to recommend adding anything to birth for every single woman. Except for maybe a skilled practitioner present (although some debate that as well, statistics are still highly in favor of the presence of a skilled dr or midwife). On behalf of my client I have had to be white stern about this postpartum pitocin and other women I know have chosen to do it and. It really felt strongly about it. If I've had an epidural I would probably not argue too strongly this point since I have interfered with my oxytocin and may not be as successful in expelling placenta, but not necessarily. I think we as a society like to believe we are in control and that doing is always better than not doing, hence the term "active management". But you and I as good doulas know this just isn't true! I believe our birth outcomes, maternal and infant mortality and morbidity rates would drop dramatically if we adopted a less active management policty for every step of birth. The terms we use for the mother are always so negative (incompetent cervix, failure to progress) and the terms we use for the doctors part so positive (delivered the baby, active management, performed a ____). Perhaps if we instead saw the mothers job as active management and the physicians (if he need be involved at all) as patient availability we would have happier moms and happier babies. Great blog!


  3. Thanks for the comments! Watching the physicians pull the BABY out makes me cringe... let alone the umbilical cord. Bleh. Why rush it?

    I've never seen it take longer than 30 minutes for the placenta, and frequently less, in the hospital. They just don't wait that long. And everyone is standing around - the baby nurses, the care provider, the l&d nurse, to move on to the next step.

    My mother had to have her placenta manually removed. They gave her meds and the doctor went all the way up into her uterus. That does not sound like fun! And it can be avoided in some instances if people have PATIENCE! :)

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