Third stage of labour

newborn baby after birth

The third stage of labour starts with the birth of your baby and ends after you have delivered the placenta – the organ that's been busy in your uterus, giving your baby oxygen and nutrients and taking out the trash (sort of an internal housekeeper). Having just pushed a whole human out of your body, you might be forgiven for thinking that a third stage is beginning to take the mickey. But you’ve started so let’s finish.

What happens when you give birth to the placenta?

Once the second stage of labour is over and your baby is out, your midwife will clamp and cut the cord. However, if you want to go the natural route and there are no complications, all this can be done at a slower pace and you can wait until the cord has stopped pulsating, or even until the placenta is delivered, before cutting it.

Light contractions will then start again and help the placenta break away from the uterine wall. As it does so, the blood vessels inside the uterus will seal.

After all your recent exertions, you may still need to push a few more times and the midwife might apply pressure to your abdomen while keeping hold of the umbilical cord, but compared to what's gone before, this is usually a doddle. The placenta is much softer and smaller than your baby so delivering it feels more ‘weird’ than ‘painful’.

Depending on your circumstances, you can choose between expectant or active management of this third stage – in layman's terms that’s the natural route or having an injection to help things along.

What is expectant management?

This is where the whole process takes place completely naturally (also called a 'physiological' or ‘natural’ third stage). Essentially, you just wait for nature to take its course, so the baby is born but remains attached to the cord until it stops pulsating, rather than the cord being cut and clamped.

Contractions will start again, and the placenta will peel away from the wall of the uterus and drop into the vagina. At this point you’ll probably feel the urge to push again and the placenta will be delivered.

This whole process can take between 15 minutes to an hour and the umbilical cord will only be clamped and cut once the placenta has been delivered.

If you prefer, you can do a sort of ‘half-half’ third stage where you ask for the cord to be left intact until it has stopped pulsating, but then have it cut and have the syntocinon injection to encourage the placenta on its way. If a natural third stage is taking its time, you may be advised to do this anyway.

What are the benefits of a natural third stage of labour?

I had a physiological third stage so wanted loads of skin-on-skin time, a first feed and the cord not to be cut until it had stopped pulsating. There was no rush for the placenta to be delivered… until the after pains kicked in. Then it felt like I was having another baby!

A natural third stage means that your baby gets an extra shot of oxygenated blood and stem cells from the placenta following birth, as the cord is not cut immediately. The additional blood will help fill out all the vessels around your baby’s lungs, making his first breaths easier to take.

Many women are of the opinion that simply letting your body do what it’s designed to makes a lot of sense, and that it’s a bit of a shame to see that cord blood go to waste when it could go in your baby.

A natural third stage also gives you the chance to bond with your baby immediately after birth. No one’s going to be suggesting he’s whisked off for cleaning up etc when he’s still attached to you after all. It’s a special few minutes.

What are the risks of a natural third stage of labour?

Provided you are healthy and your pregnancy and labour were free of complications there should be no problem at all. However, a natural third stage can mean you bleed more heavily immediately after the birth.

If you are anaemic, malnourished or in any other way not on top form, you may be advised to have a managed third stage. This will also be the case if you had heavy bleeding in pregnancy. If your womb was particularly stretched, for example if you were pregnant with twins, had a very large baby or had polyhydramnios (too much amniotic fluid) you may also be advised against going the natural route, as these, too, increase the risk of heavy bleeding.

On the plus side, women report having less post-birth bleeding in general following a natural third stage.

Are there any tips to help with a natural third stage?

There are a few things you can do to help nature on its way once your baby’s arrived but the placenta is still to make an appearance:

mother breastfeeds newborn

  • Breastfeed as soon as you can after birth. Breastfeeding will stimulate the body’s production of oxytocin, the feel-good hormone, which in turn makes the womb contract.
  • Have lots of skin-to-skin time. Get your baby straight onto your bare chest after birth. Again, this will get the oxytocin flowing and trigger contractions to push out the placenta.
  • Relax and enjoy it. This is the easy bit and the worst is all behind you. Lots of women say they barely noticed their third stage, so little impact did it make. If you’ve got a really helpful midwife she might even get the tea and toast on at this stage.

What is active management of the third stage of labour?

A ‘managed’ third stage is what most hospitals recommend as there is less chance of blood loss with this option, but you’re absolutely within your rights to ask for something different. Just talk to your midwife about it and make sure it’s in your birth plan.

That said, depending on how you're doing, and what medication you have received during labour, you may have to have active management as there are some situations where a physiological third stage is considered unsafe.

Active management means that when your baby is born (or sometimes even as he’s making his exit) you’re given an injection of syntocinon or syntometrine in your thigh to help the uterus contract and minimise blood loss. This is basically synthetic oxytocin and does the same job of contracting the uterus.

As soon as your baby is born, the umbilical cord is clamped twice – once about 3-4cm from your baby’s belly button, and a second time further up nearer the placenta. It can then be cut. You can actually do this yourself if you like (obviously under a midwife’s supervision – don’t just take your nail scissors in), or it’s often a job that the partner likes to do. Cutting the cord doesn’t hurt either you or your baby as there are no nerves in it.

Your midwife will apply a little bit of pressure to your tummy with her hand, to check that the placenta seems to be coming away from the wall of the uterus. She’ll then gently pull on the cord to ease the placenta out. This is known as ‘controlled cord traction’.

Regardless of which option you choose, if you are planning to breastfeed it's a great idea to give it a go as soon as possible, as doing so will help your uterus contract. We told you Mother Nature was clever.

What are the benefits of an actively managed third stage?

It’s nice and simple and it’s what the midwives will probably be used to doing. It does usually speed up delivery of the placenta a little bit, too.

I was too busy staring in awe at my gorgeous daughter to notice this bit, to be honest!

There’s less chance of you losing a lot of blood and, if you’ve had any complications in pregnancy, such as bleeding or a twins pregnancy, or difficulties in labour, including having had an assisted delivery using ventouse or forceps, you’ll be advised to have an actively managed third stage for that reason.

Are there any side-effects of an actively managed third stage?

Active management is completely safe but syntocinon does cause nausea and vomiting in some women and can also cause an increase in blood pressure.

What happens after the third stage of labour?

Once the placenta is delivered the midwife will check it over to ensure it is ‘complete’ and there aren’t any pieces of it remaining in the uterus.

It’s worth asking for a look at this point if you feel up to it. The placenta is pretty awesome and looks like a giant, floppy, red frisbee. Midwives tend to be fairly brusque with them and flap them about and fold them up like hospital sheets. It’s all quite impressive.

Assuming all is intact, you might be given stitches and then helped to have a shower, breastfeed your baby some more and generally start getting yourself sorted out.

What is retained placenta?

Occasionally, the placenta breaks down a bit on exit. This is slightly more likely if you’ve gone overdue and if you’re an older mother, particularly if you were over 40 in pregnancy. Sometimes bits of placenta get stuck to old caesarean scar tissue or similar.

If it looks like there is some placenta stuck up there still, you’ll be given a surgical procedure called a ‘manual extraction’. We’re afraid this is exactly what it sounds like but you’ll be given an anaesthetic to get you through before the surgeon does the James Herriot bit.