The Third Stage of Labour: Delivering the Placenta

Mothers of Change has published a number of posts on placentas.  First, an informative look at what placentas do and how they function in The Placenta, then a post on the various things families do with placentas called Placentas: Love Them or Leave Them, and a peek at placentophagy in Placentas: Love Them or Eat Them.  The placenta is so fascinating.  It is the only human organ that develops for short term use, and is discarded afterwards.  Fetal life cannot be sustained without it, and it does an amazing job transferring nutrients, waste products, and oxygen to and from mother and baby during pregnancy.

Birth is divided into three phases by medical science.  The first stage, which includes dilatation, early and active labour, and is the longest stage.  The second stage of labour is the expulsion, or ‘pushing’ stage.  The third stage of labour, which often gets little attention from parents because everyone is focused on the fresh arrival of a new infant, is the placenta expulsion stage.  It is an important stage physiologically, and there are two common ways to facilitate it.

The medical model of care will frequently choose active management of this third stage of labour.  Active management involves the administration of oxytocin: with an intramuscular injection or an IV infusion, after the delivery of the anterior shoulder or as soon after birth as is possible.  It also includes clamping of the cord and controlled cord traction to facilitate delivery of the placenta.  While the placenta is still in the uterus, maternal hemorrhage is more likely and more difficult to control.  [Other methods for controlling PPH are still utilized, from uterine massage and tamponade to surgical clamping of uterine arteries, but active management focuses on preventing PPH and/or reducing its severity].

Postpartum hemorrhage is rare in healthy, well nourished women.  But it is still the leading cause of maternal death in Canada as well as worldwide, in developed as well as developing nations.  Investigating medical management methods and prevention tools for this life threatening event during birth is valuable:

“Postpartum hemorrhage is the leading cause of maternal death worldwide, with an estimated mortality rate of 140, 000 per year, or 1 maternal death every 4 minutes.  PPH occurs in 5% of all deliveries and is responsible for a major part of maternal mortality… Nonfatal PPH results in further interventions, iron deficiency anemia, pituitary infarction (Sheehan’s syndrome) with associated poor lactation, exposure to blood products, coagulopathy, and organ damage with associated hypotension and shock (SOGC, Prevention and Treatment of Postpartum Hemorrhage)”

*note: this SOGC guideline recognizes the benefit of waiting 1 to 3 minutes after birth before clamping and cutting the cord, and recommends waiting this interval before performing this part of the active management method.  This is considered ‘delayed cord clamping’ by the medical community.  It is not considered delayed by all definitions, however, since research into cord clamping practices shows maximum benefit to be incurred if clamping is delayed until the cord stops pulsing, which generally happens before 3 minutes but not always*

Research clearly shows that active management of the third stage, including oxytocin administration, cord clamping, and controlled cord traction, are effective in reducing the incidence of postpartum hemorrhage.  The risk of PPH is the reason that the International Confederation of Midwives and the International Federation of Gynaecologists and Obstetricians have recommended that all births be attended by a care provider trained in the treatment of hemorrhage during birth, including controlled cord traction and uterine massage, and have access to the use of uterine tonic drugs such as oxytocin.  The Cochrane Collaboration (a highly respected medical research resource guide) agrees, as does the World Health Organization. 

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The other method of dealing with the third stage of labour is known as the expectant management, or sometimes physiological management method.  Expectant management involves allowing the placenta to deliver spontaneously or aiding by gravity or nipple stimulation. This method is frequently favored by care providers and women who embrace a midwifery model of care, or whotrust nature’s design over scientific involvement in the birth process.  Not all midwives practice expectant management and not all physicians practice active management.  These are simply styles of practice which generally align with each model of care.  In fact, Canadian women have the freedom to chose which style of management fits their situation the best, and their care provider is required by medical ethics and by law to either provide the style the woman chooses, or refer her to a care provider who will.  Practitioners who use expectant management would prefer to address postpartum hemorrhage if it occurs, with evidence based methods for addressing this critical complication, such as oxytocin administration, uterine massage, placenta removal, fluid replacement, blood transfusion, and surgical intervention if needed.

Proponents of expectant management interpret research findings with caution.  Indeed, both the Cochrane Collaboration and the World Health Organization point to weaknesses in the research on active management to date, including the broad application of active management methods to healthy women in developed nations.  The World Health Organization publication on active management points out that within the research there are different definitions of active management in different hospitals and countries.  Some studies include early cord clamping, others late.  Some include uterine massage and assessment of tone, and others do not.

“The greatest potential value of this policy, however, would be in the developing world where the consequences of PPH are more likely to lead to long term morbidity or even death. Further trials in such settings are therefore urgently required (Cochrane Review).”

Proponents of expectant management would state that good nutrition, healthy spacing between pregnancies, safety from domestic violence, and overall good health are postpartum hemorrhage prevention strategies already in place for the majority of their clients, particularly in Canada.  However, the SOGC states that the majority of PPH cases are attributable to poor uterine tone and not associated with any risk factors, but it is also true that the rates of PPH and associated mortality are up to six times higher in poor countries with little access to good nutrition, family planning, female emancipation, and overall good health.  This is a confusing message, but logic says that healthier women are at lower risk of PPH overall.

Expectant management also looks at an overarching view of health.  Active management does reduce the incidence of PPH, but does it increase the chance of an infant having problems associated with early cord clamping, such as low ferratin levels at six months of age?  Research on active management has rarely looked at short and long term infant outcomes or aspects like breastfeeding rates or mental health outcomes, because its focus is on postpartum hemorrhage.  The impact of artificial oxytocin on the cascade of hormones after physiological birth, which facilitates bonding, lactation, latching on and effective milk transfer has not been studied.  Interference in the birth process can cause iatrogenic problems, and the third stage of labour is no different from other stages in this regard.

The most common concern with the active management approach is its emphasis on cord clamping.  If cord clamping is a priority because of a focus on preventing PPH, it can occur earlier than is physiologically appropriate.  Some cords continue pulsing for longer than three minutes, and some care providers would consider clamping at one minute postpartum to be ‘late’ and safe, without assessing clinical signs such as cord appearance and pulsation.

“Delayed cord clamping provides physiological benefits to the baby, and psychological and emotional benefits to the mother. These factors should compel caregivers to honour the sanctity of the mother/baby union during the moments that the newborn is between two worlds and the mother is seeing and experiencing her child for the first time. Unnecessary interference should be avoided (Birth Journey).”

“In a physiological third stage of labour, as a natural progression from a natural, normal physiological labour – the woman is in control. She is in tune with and has faith in her body’s natural ability to complete the birth of her baby. As in the labour, the midwife’s role is to support that process – not control it. The midwife is trained to detect problems and to take actions to ensure the safety of the mother and baby. The midwife is entrusted with this responsibility as an integral part of the relationship. It should be a partnership, not a dictatorship (Birth Journey).“

The desire for physiological birth and for maternal autonomy are not simply emotionally based preferences.  Research into a supportive and empowering approach to maternity care shows that fewer problems occur in a supportive environment, and that caring for and supporting a woman in navigating birth as intact and healthy as possible automatically confers health upon the baby.  If the mother is healthy, so is the baby (barring rare anomalies).  If the mother is supported emotionally, her body performs its largely parasympathetic function of giving birth more efficiently and with fewer problems.  Thus, physiological management makes sense in this context.


Aside from the physiological benefits of delayed cord clamping for infants, benefits of an expectant approach include:

 ”Delayed cord clamping allows the baby’s lifeline to continue to supply oxygenated blood, facilitating perfusion of the lungs, and supporting the baby’s transition to breathing for himself without incurring oxygen deprivation. The baby is less likely to require resuscitation after birth, and less likely to have idiopathic respiratory distress. (The term Ideopathic Respiratory Distress describes breathing difficulties for no apparent reason, and is believed to be linked to interference with the delicate and complex changes in the baby’s heart and circulatory systems – Dunn, 1989; Inch, 1983)
Delayed cord clamping reduces the risk of feto-maternal transfusion, which is especially important for Rh negative mothers (Lapido, 1971; Rogers et al, 1998).

Delayed cord clamping reduces the risk of infection in both the mother and the baby because the mother has reduced clot formation if the maternal end of the cord is not clamped, and the baby has less stagnant blood left in the cord stump. Clots and stagnant blood provide an ideal environment for infection. The cord may separate more rapidly postnatally if cord clamping is delayed (Sleep, 1993).

Avoiding controlled cord traction eliminates the risk of pulling out an incompletely separated placenta, tearing or snapping the cord, partial or full inversion of the uterus, and pain associated with uterine handling, which also interferes with the myometrial action of the uterus which maintains uterine tone.

The woman and baby can remain undisturbed and unhurried, enhancing bonding opportunities, facilitating early breastfeeding and maximising hormonal balance (Birth Journey).”

It is also important to consider the fact that management of the first and second stages of labour were not differentiated in any of the studies which favored active management.  If a woman’s natural body process has been circumvented by active management of first and second stages of labour, this could affect her outcomes for the third stage of labour.  Induction, augmentation, pharmaceutical pain relief, limited movement, external fetal monitoring, fluid boluses, and frequent disturbance by medical staff could cause iatrogenic effects on the physiological process which could then cause problems in the third stage.  Active management of labour could lead to the need for active management of placenta expulsion and the prevention of PPH.  Research has not separated out physiological management of the third stage in association with how the first and second stages are managed.

The environment is also important, since a woman’s body is more efficient at producing natural oxytocin in a warm, calm, supportive environment, while in skin to skin contact with her newborn baby, and breastfeeding him or her when the baby shows interest.  If she is undisturbed by hospital protocols, and not separated from her baby, her body produces more oxytocin, and her body can do the job of preventing or minimizing postpartum hemorrhage more effectively.  And on its own power.

“Active management illustrates the confusion in the medical approach as to what is normal and what is pathological in birth… The entire modern obstetric and neonatology literature is essentially based on observations of medicalized birth ( Marsden Wagner).”

“The techno-medical model of maternity care, unlike the midwifery model, is comparatively new on the world scene, having existed for barely two centuries. This male-derived framework for care is a product of the industrial revolution. As anthropologist Robbie Davis-Floyd has described in detail, underlying the technocratic mode of care of our own time is an assumption that the human body is a machine and that the female body in particular is a machine full of shortcomings and defects. Pregnancy and labor are seen as illnesses, which, in order not to be harmful to mother or baby, must be treated with drugs and medical equipment. Within the techno-medical model of birth, some medical intervention is considered necessary for every birth, and birth is safe only in retrospect (Ina May Gaskin).”

The choice between active management  and expectant management of the third stage of labour lies with the woman who is giving birth.  Discussion of her choice should take place during prenatal appointments, and a plan of action agreed upon and honored during the birth.  Women are smart and capable, and no two of us are exactly alike, and our decisions will reflect this.  What is right for one woman is not right for another, and the freedom to chose is imperative.