Active vs expectant management of 3rd stage

[MyThumbsHaveGoneWeird]

Please help me make a decision on this. I am finding it impossible!

My instincts are that if I have had an intervention free labour and birth I would prefer to remain intervention free and have delayed cord clamping and a natural 3rd stage. But then I think is it really sensible to demand to go against about 30 years of standard practice, when there is good evidence that it does reduce post partum haemorrage here and BMJ 1988 and lancet 1998.

But then I read things like this(bottom right of page) which make me wonder about all those other studies and whether the conditions they were conducted in would be different to mine. A natural 3rd stage seems to cause less nausea and vomiting, less neonatal jaundice, and less chance of retained placenta. But am I just looking for evidence to support this because I am generally anti-intervention? Do these things outweigh the increased risk of PPH? If I do manage to have an intervention free labour and manage to start breast feeding quickly (big ifs I know) then does that put me into a very low risk group and therefore make the above PPH studies less applicable?

I really need to discuss this with you all to get my head straight!

I would like to have had a natural third stage this time, but as I'm having a homebirth the midwife felt much happier for me to have the injection (my feeling is that because the placenta generally takes longer to detach in a natural third stage then overall you bleed more because you are bleeding for a longer period of time. Not the same thing as a higher likelihood of PPH IYSWIM). So my compromise is that I am going to insist that the cord stops pulsating completely before it is cut, and this will also ensure me lots of lovely cuddles and calm just after baby is born, before they do all the clamping, weighing etc. I think it is really important to have that skin to skin time because it reduces the likelihood of baby getting cold, and if baby has his first feed before the cord is cut, this is likely to bring the placenta quicker and might actually mean not needing the injection at all. But we'll see how it all pans out. Either way, I will not let them near the cord until it stops pulsing, even if it is short or baby needs resusc. That can all be done with cord intact. HTH. Oh, and btw I've read that jaundice has a lot to do with early cord clamping, as does newborn anaemia. (Some huge percentage of baby's blood volume is still in the placenta and cord at birth).

So can you have delayed cord clamping but still have a managed 3rd stage? I thought they had to give you the injection as soon as the baby is out, and that meant they had to also clamp the cord immediately. I didn't know there was a sort of half way option. Do they do the injection after the cord clamping in that case?

I had physiological third stage which took about 20 mins. But then i started bleeding and they had to put a drip up and i was in overnight. Dunno what I'd do next time. There was nothing to suggest that i was at any risk of a bleed - so maybe it was just one of those things that wouldn't happen again??

There is some more good info here=
www.homebirth.org.uk/thirdstage.htm
and
www.midwiferytoday.com/articles/bristol.asp
www.midwifery.org.uk/index.php?option=com_content&view=article&id=231:the-third-stage-and-post-partum-haemorrhage&catid=91:hidden-archives&Itemid=110
www.childbirthsolutions.com/articles/birth/thirdstage/index.php
Many of my clients have had a physiogical third stage.
As you say, if you have had a narmal, intervention free labour then it seems logical to have a physiogical third stage.
You can delay cord claming then have the injection, or only have the injection if you start to bleed heavily.
Selina

I've got it in my birth plan that I'd like to try for a physiological 3rd stage if clinically appropriate. If I'm bleeding heavily or we try and it's going too slowly for the doctors liking, then I'll happily have the injection. But if labour has gone okay and I'm not bleeding heavily, then I'd like to at least try for a natural 3rd stage.

I don't think it has to be black-and-white - you can see how things go.

Thank Selina, those links are really interesting. However, the quotes all come from people who (like me) seem to be very instinctively anti-intervention. I do usually just trust my instincts, but in this case they do seem to go against ALL the research data. Do you know of any studies which back up these pro-physiological 3rd stage opinions?

I like the idea that it doesn't have to be black and white. I might put something like you have in my birth plan japhrimel.

i read that link - it didn't mention whther women truly did have a 'natural' third stage, that is, whether the baby was skin-to-skin and feeding in order to trigger the release of natural oxytocin. The study in 1998 didn't say. i'd assume the one in 1988 that they weren't.

If not, they haven't got a picture of a truly 'natural' third stage.

I had natural 3rd stage for all three - though the MW (another Selina :) ) at my last one did say i was at increased risk of PPh due to the large numbers of pregnancies i'd had, and got my consent to jab me with Synto if i started to hose down.

I had a managed 3rd stage with dc1, ended with massive blood loss and retained placenta that was manually removed immediately post-delivery and then the bit that they had managed to leave behind they removed under a general anaesthetic at 12 weeks post-delivery. All in all a horrible experience which on further reading I felt was due to the sytometrine and ergometrine that I was given.

Discussed with consultant during 2nd pregnancy that I would like a physiological 3rd stage and he agreed that it might help. It was great, very little blood loss and felt so much better. Syntometrine can without doubt prevent PPH in some cases but is not without side effects as with all drugs, it can also be given at any stage so it is possible to have it on standby in case.

AIMS do a brilliant booklet called "delivering the placenta" which discusses all the relevant research and pros and cons. It is available on their website. Also bear in mind that a lot of the research on a managed 3rd stage preventing PPH has been done in developing countries without taking into account the levels of maternal health pre pregnancy/delivery, numbers of pregnancies and blood levels. Good luck with your decision.

interesting..(though slightly shocking the way they casually 'assigned' groups!)

i notice that late cord clamping is definitely better for the infant, retaining an additional 85g average of weight of blood.

to be honest, i hadn't researched this before giving birth.

Most studies do show a reduced incidence of PPH with active management
[[http://clinicalevidence.bmj.com/ceweb/conditions/pac/1410/1410_I1.jsp}
So one study for Mild PPH 10% less with active management.
And for Severe (>1000ml) !% with active management, 3% with physiogical third stager.
In my own research (Masters dissertation unpublished)
Found that women that had Physiological Births without active management of the third stage (so no systemic pain relief either)
was associated with-
Greater odds of breastfeeding after delivery 1.78 CI1.09-2.92
and on discharge 1.24 (0.74-2.06)
Lower odds of babies being born in a compromised condition (APGAR 1 Min

Also an obstetrician here in Liverpool, has published about delayed cord clamping especially in cesareans with low birth weight babies-
www.bmj.com/content/335/7615/312.full

In my experience, physiogical third stage is a much gentler transition for the baby. It is still getting oxygenated blood as its body systems swithch over to breathing air.
For some babies that are shocked by a quick birth or a very long one, that extra oxygen they receive could be really important.

Selina

just read through one of your links about the 'Bristol' study - tis a bit of a pile of crap isn't it?

basically the study assumes that the 'physiological' group was handled as per their definition of physiological, when in fact, it seems likely that it wasn't - the same staff in the same birthing culture did both groups, and thereofre i am very sceptical that this was the case (ie that the cord was cut late, that BF was initiated straight away, that the mother was not made to feel hurried about delivery of placenta...some of the women still received prohylactic oxytocin anyway ....it seem they are really measuring 'active' vs 'half-arsed active')

if i have understoof the 'midwifery today' article, it advocates playing it by ear - and injecting with synto only if necessary.

I have a question re: having the injection, presumably the syntocin (sp?) doesn't actually cause the placenta to detach from the uterus, it just causes some extra strong contractions to encourage it to exit the uterus, so what if the placenta has not actually finished detaching when the drug causes the contractions, isn't this increasing the likelihood of a retained or partially retained placenta? And surely once those big contractions are over and done with, your cervix is going to start to close, possibly trapping the placenta? I get the feeling that when the injection is given there is a great panic to deliver the placenta, knowing that the clock is ticking before the cervix closes, is that true? It seems to me that there is less reason to be nervous over the time it takes for the placenta to arrive in a non-medicated third stage...?

I'm struggling a bit with this as I know my midwife really wants me to have the injection because I'm having a homebirth (and I've agreed to have it), so presumably she is more comfortable with giving it than not, but is it fair to say that one could do a "wait-and-see" approach, and if after 15 or 20 minutes no contractions have occurred to push out the placenta, it would then be reasonable to have the injection (given that that extra time should have allowed the placenta to detach in one piece)?

sarahbuff -

had 3 homebirths and so far no MW has even mentioned managed 3rd stage. it is up to you.

There are 2 types of injections given routinely after birth, syntocinon and syntometrine. Syntometrine has syntocinon plus ergometrine and therefore is the stronger and more effective drug at stopping bleeding. Unfortunately the ergometrine is also what makes you sick.

If you have a normal physiological labour with no intervention at all, then there is no real reason to have any injection afterwards.

In my practice as a midwife, what I do is baby skin to skin and cord pulsing for 5-10 minutes then when the parents are ready they can clamp and cut the cord, but its important to have at least 3 minutes of placental blood back into the baby. (cant find the research article for this atm sorry:))
Then when the cord is cut I give the syntocinon (which doesnt induce vomiting) and doesnt shut the cervix too fast, then I deliver the placenta as its usually seperated by then. I find that syntometrine will shut the cervix a bit too quickly and can end up with a retained placenta.

This is my standard practice if a woman has no real preference, (and youd be amazed at how many dont!) and I have hardly any retained placentas, (think I have had one in the last 200 births) and no more haemorrhages than normal.

There are some things that will predispose a woman to a PPH or will make it more serious if it happens such as a low haemoglobin, previously having had a pph or intervention like syntocinon or epidural or very long or very fast labours, and then I tend to be more inclined to suggest syntometrine than syntocinon.

All a bit anecdotal but I hope this helps.

Thanks for the very insightful response mintpurple! I am hoping that by waiting for the cord to stop pulsating, I'll give myself a chance to possibly deliver the placenta already by the time the midwife starts worrying about giving the injection. I plan to spend the labour upright and give birth squatting or kneeling, so hopefully staying in that upright position after the birth will also help to encourage the placenta out. I'd love it if I could deliver the placenta with the cord still attached! We'll see how it goes though. Sorry to have slightly hijacked your thread, mythumbs!

I had managed third stage with DC1 and physiological third stage with DC3. Retained placenta both times!

More jaundice with DC1, but the breastfeeding didn't establish well. DC2 (also managed third stage) had no jaundice.

I felt most nausea with third delivery.

Sorry, absolutely no help!

marking my place for a poper read later

I had a natural 3rd stage with DD, midwifes idea. Initially I thought I had a lot of blood loss but it stopped much earlier than with Ds when I had the injection eg: 2-3 days with DD vs a week or so with Ds the midmives said this was quite common. I don't think it took as long as 20 minutes for the placenta to deliver in either case tbh.

I wanted an unmanaged third stage, it was in my birth plan. But I had a big tear and needed stitching up without much delay, so the mw gave me the injection without even asking me. Was the best thing though, I'm perfactly hapopy that the mw made the right decision. It's not worth worrying about too much IMO.

mintpurple I like the sound of your approach, I think I will definitely ask for delayed cord clamping.

Selina Thanks for posting your unpublished research. Is that data from an observational study or a randomised trial?

Sarahbuff No problem! You asked all the questions I would have!

I had managed third stage. Reason was that I have quite large fibroids in an awkward position, massively increasing the risk of PPH. DD did have jaundice, not sure what caused it, could also have been ventouse. However, in the end both of us are fine.

Friend had natural third stage, had massive PPH and retained placenta. Took her months and months to regain strength, she had a very rough start and was totally exhausted.

I had a natural 3rd stage without fully understanding it - had not read up on it, and just asked in my birth plan for everything to be non-intervention if poss. Had a natural birth, no probs, but then just thought oh WHAT? when the midwife said I still had to deliver the placenta! But it only took about 10 mins, when I put dd to the breast it literally whooshed out, scared the hell out of me. But no problems at all and would hope to do the same next time.

Really interesting thread. I had very much wanted a natural third stage, but things went awry, and after a long labour (19 hours), an hour and a half of pointless pushing when even I knew something was wrong and didn't want to push, I had an em c section when they discovered my son was mahoosive and stuck in LOT, obviously they then managed the removal of the placenta, but an hour or so later I then had a pretty big PPH (1300ml) and ended up in high dependency overnight. DS ended up with mild jaundice and we only just got BFing established. According to my notes the PPH was due to an atonic uterus.
Selina and Mintpurple would it be utter madness for me to consider a natural third stage in a hypothetical future pregnancy, assuming I could have a successful VBAC or was this bleed likely to be a result of the failed labour and not necessarily something that would happen again? I am not out to be a martyr, and know the bleed scared my husband more than anything that day, but would love a future child to have a less brutal start in life than my DS.

Id say that the atonic uterus was most likely caused by the long labour and pushing stage and if you had a quicker labour next time it would probably be ok. Id still probably recommend at least a syntocinon injection though. Or at least have a low threshold for giving it if you started to bleed again.

Can almost guarantee a bit of pressure from the docs to have it next time though and probably also a couple of hours of a strong syntocinon infusion through a cannula, just to tighten up the uterus after your next baby.

I don't think it would be madness to refuse this but as it scared you both last time, I do think it would be better to have it, one less thing to worry about afterwards, and you will probably be just waiting for the bleeding to start....