Why the third stage of labour should be more than an afterthought

How many of us spend time considering birth preferences for the third stage of labour ? Very few, and yet what happens between the birth of baby and the expulsion of the placenta can have a significant impact on our birth experience.  During the third stage of labour, the placenta separates from the uterine wall and the uterus contracts to expel it. As the placenta separates, there is some bleeding from the area of the uterus where it was sited. The amount of bleeding varies from woman to woman – blood loss greater than 500ml is considered a post partum haemhorrage.

Currently, the policy in all Irish maternity units is to carry out a managed third stage of labour. This involves giving an intramuscular injection, of either syntocinon or syntometrine, into the thigh.  Many women will not even know they’ve had this – they are so engrossed in their newborn that it doesn’t even register. Once the injection has been given, a strong surge usually follows and the placenta is often expelled quickly. Your midwife will feel the uterus to see if the placenta is separating from the wall of the uterus and may use what is called controlled cord traction (pulling the placenta out) to hurry the process along, or may encourage you to push it out.  If you have a managed third stage, your risk of  a post partum haemhorrage (PPH)  is reduced.

The alternative is to have a physiological third stage.  The placenta is left to separate itself, without drugs to speed up the process. It should be expelled using maternal effort, rather than being pulled out. Although a managed third stage is recommended based on current research which shows it lowers the risk of PPH, a study comparing physiological third stages in settings that do not fully support that mode of birth and settings that do is not available. It has been observed by midwives that women who have a physiological third stage may bleed more immediately after birth but then bleed less post partum than those who have a managed third stage, but this is anecdotal rather than backed by evidence.

The vast majority of women will have a managed third  stage, as part of the standard package of hospital based maternity care. In a home birth setting, most women will have a physiological third stage and have no problems with blood loss. In the midwifery led units (MLUs), physiological third stages are far from unusual. But how can you decide what is right for you?

Dr. Sarah J. Buckley believes that we should resist intervening in the third stage of labour, if all has been well up to that point.  The birth process is driven by hormone interactions which, when disturbed by some routine hospital procedures, can have negative consequences for mothers and babies. The drug given in the third stage of labour is an oxytocic drug – it is a synthetic version of the naturally occurring oxytocin in our bodies, which is at its highest level just after the birth of our babies.  Oxytocin is released as we gaze at and touch our wondrous newborn, and yet more is released if baby makes her way to the breast and nuzzles and latches on. The levels peak around the time that the placenta is expelled. So if our body already has everything it needs to do the job, why do we need an injection to help?

Midwife Rachel Reed, author of the Midwife Thinking blog, explains here why the hospital environment is not always conducive to a physiological third stage of birth.  Many women arrive at the third stage after having interventions along the way – birth has not been physiological up to that point. Furthermore, the third stage of labour is a time when mother and baby should be left undisturbed, to get to know each other. Uninterrupted skin-to-skin should be facilitated, to allow oxytocin levels to reach their natural peak – no weighing or other checks that separate mother and baby should be carried out. There can also sometimes be fear in the room if staff are not used to facilitating a physiological third stage – this stress, and the time pressure (sometimes hospitals will put a limit of 1 hour on a physiological third stage) can cause adrenaline release in the mother, which can suppress oxytocin release. My own experience, as a doula in Irish hospitals, is that some staff can become nervous as the hour approaches and the mother begins to feel pressure to perform and produce the placenta – not the ideal environment.

So if a managed third stage means less chance of a post-partum haemhorrage, why would you consider a physiological third stage?  Well, a recent study suggests that breastfeeding duration may be affected by administration of drugs for the third stage of labour.  Women who had had oxytocic drugs for the third stage of labour were significantly less likely to be breastfeeding at 2 and 6 weeks and were more likely to have stopped due to pain or difficulty breastfeeding.  More research is needed to examine why this might be the case.

Another risk is that after the administration of the drug, the uterus may clamp down and start to close, trapping the separated placenta inside. This is why controlled cord traction is used, to help the placenta be expelled quickly. If the placenta is trapped inside, it will need to be removed manually in theatre.

Some women can feel sick, dizzy and too unwell to hold their babies after administration of the third stage drug. This is generally due to syntometrine rather than syntocinon being used. Syntometrine is a combination of syntocinon and another drug called ergometrine, and while effective at preventing haemhorrages, it somes with a list of unpleasant side effects. For this reason, Irish Obstetric Guidelines for preventing PPH recommend that syntocinon be used routinely, where the woman is not at increased risk of PPH. It is worth noting that the manufacturer instructions for syntometrine state that it can “inhibit prolactin secretion and in turn suppress lactation”.  If you are attending a maternity unit where syntometrine is used routinely (Waterford and National Maternity Hospital being two), then you may want to have a birth preference that requests syntocinon, should you be planning a managed third stage or in case it becomes necessary.


If you have had a physiological or minimal intervention birth up to the third stage, then you may feel it makes sense to try for a physiological third stage.  GentleBirth women often have confidence that their body, which has grown their baby from two cells and then launched it into the world with no conscious effort on their part, can finish the job on its own.  The injection can be drawn up and ready to go, in the event that you begin to experience significant blood loss. This lovely article describes facilitating a relaxed third stage of labour. Midwives in Irish hospitals are thankfully now becoming more familiar with physiological third stage, as more women are deciding that this is the best option for them and their baby.  As suggested in the article, maintain the ‘mood’ in the room, whether you birth at home or hospital. Leave phonecalls and texts until after the birth of the placenta. Stay together with your birth partner and supporters and marvel at the new being who has just come into your life. Examine your baby’s face, those teeny fingers and toes. Let baby crawl to your breast and familiarise herself with the new territory. Forget the clock – as long as there is no significant blood loss, the third stage of labour should not be time-limited.  If there is a delay, getting into an upright position such as on the toilet can encourage the placenta to plop out. Most women will deliver their placenta within the first hour after birth, that magical period when you are getting to know the new and wonderful person you have brought safely into the world.

As with all birth preferences, there is no right or wrong answer. Being informed and having decision-making tools will mean that you can make the best possible choice for you on the day.

Further reading
Dr Sarah J Buckley on third stage physiology: http://www.birthspirit.co.nz/leaving-well-alone-third-stage-labour/
Midwife Rachel Reed discusses why a managed third stage may be the best option: http://midwifethinking.com/2012/05/05/an-actively-managed-placental-birth-might-be-the-best-option-for-most-women/
Gloria LeMay on the 30 minute third stage: http://www.glorialemay.com/blog/?p=161
How the placenta grows, functions and is birthed: http://42weeks.ie/2013/08/28/the-mysterious-placenta-and-the-third-stage-of-labour/