what's the big deal about physiological third stage?

[stella1w]

I'm pg for the second time and hoping for a home, waterbirth with hypnosis so I am very pro-natural approach.
However, I am very confused as to why having a physiological third stage is so important..
The midwife on the home birth visit this week said I had to decide in advance whether to have the injection or not (not sure why I couldn't just wait and see) so I erred in favour of injection..
But am worried I am missing some important point here!

As I recall from the NCT classes - babies are less likely to become anaemic with a physiological third stage as more blood is transferred from the placenta into the baby. Difficulties can arise if the placenta doesn't detach naturally though, and people have had to go into hospital by ambulance after a home birth to get the placenta out.

Allowing the cord to stop pulsating before it is clamped allows more blood transfer and supports your baby whilst he/she takes over running the show. Once it's stopped and been clamped i'm not sure what the difference is between physiological and injection but it'll only affect you and not the baby.

Read this - brilliant information and statistics on all the options:
www.homebirth.org.uk/thirdstage.htm

It's good practise to let the umbilical cord stopping pulsating whether you have a physiological third stage or not.

You can tell the midwife you will have the injection if medically necessary.

I had a managed third stage for all three of my births (including both home water births) because I bled a lot after each birth.

Your midwife can't make you decide now.

I've alwasy said,
1/ delayed cord clamping
2/ try for a natural 3rd stage
3/ once cord has stopped pulsating (usually about 20 minutes for my babies, but in some women its much shorter) and is cut, if there are medical reasons why accepting the injection is a good idea, I'll have it then.

The midwives have alwasy had the injection ready and waiting just in case. They would like me, with my 5th (due imminently) to opt straight for the injection sue to increased risk of PPH, but I've read the stats and I don't think its significant. Having had a bad reaction to syntometrine in the past, I'm opting for the same approach as before.

So, if you've had the injection before and had no ill effects, what would be the benefit of refusing it second time?

I opted for physiological third stage following a waterbirth. This was so the full placental blood volume could transfer to the baby and she had a longer time to transition to breathing while still receiving some oxygen.
I got out of the pool, waited for the cord to stop pulsating and the cord was cut. Then I tried to push the placenta out. The MWs said it had detached and was at the cervix, but it wasn't coming out. Tried pushing it out for maybe 20 or 30 minutes. I got really fed up with all this pushing and squatting etc (they can't/won't pull on the cord for a physiological third stage). After that time I asked for the injection. I was apprehensive about a retained placenta and really didn't want to transfer to hospital (from home). So I got the injection, MW pulled on the cord, placenta came out within 5 minutes, intact. All good.
Next time, I would probably have the injection sooner, but still only after the cord had stopped pulsating naturally (e.g. 15 mins). In that time the baby can receive something like an extra 50% of blood volume, which helps the lungs inflate and may be linked to lower risk of anaemia as time goes on.

Mmmmcheese - most women who choose a physiological 3rd stage do so because they consider there are benefits to the baby of doing so.

Checkmate - do you know whether you had a bad reaction to syntometrine or syntocinon? IIRC more women react to the ergometrine, which is included in the syntometrine, than to the syntocinon - but I'm pretty sure its possible to use just syntocinon. Might be worth inquiring, even if its just the backup plan :)

Stella - If it were me, I'd plan a physiological 3rd stage and tell the MWs this. They will bring syntocinon/syntometrine (they'd be negligent not to!) so it will be there if you need it or decide you want it. Then read up on the finer points of physiological 3rd stage and get your DH to do the same - things like how a suckling baby is a key element of the process, no traction, etc. If you get fed up of waiting after 10 minutes, 1/2 hour, 2 hours, you can ask for the injection then.

Tangle - what are the benefits of a physiological third stage to the baby, as long as the managed third stage is done after the cord has stopped pulsating?

After the cord has stopped pulsating, what difference does it then make to the baby whether the stage is managed or physiological?

I had the syntometrin with DD1, 55 minutes later no placenta despite her best efforts they were about to book me into theatre for a manual extraction I believe they only have an hour to get a placenta out, one last tug and it gave way but it was horrible.

DD2 was a homebirth physiological third stage absolutely fine as was DD3.

DS was a hospital birth again asked for no injection but it was taking so long to deliver tha placenta, I was getting fed up took an hour or so in the end.

belgo - to be perfectly honest, I'm not entirely sure. I know MWs who consider that if you're having a truly physiological 3rd stage you shouldn't do anything to the cord until the placenta is out. Taken to extremes you get to lotus birth and don't clamp/tie the cord at all - I remember that there were a number of reasons why some women chose to do this, but I have to confess I can't now recall what they were with enough certainty to repeat them and I don't remember finding anything proven.

When DD1 was born the cord was clamped and cut after it stopped pulsating, but I didn't have the injection - I curled up on the sofa with DD and got on with BF and the placenta arrived at some point... There were no problems so no need to have the injection

sweetkitty - the ergometrine element of the syntometrine is generally considered to cause the cervix to close, thereby introducing an artifical time limit to how long the 3rd stage can last before manual intervention in theatre is required. This is why the risk of retained placenta is higher with a managed 3rd stage, as Loopsymumsy said above. Glad things were more straightforward with your last 3 :)

You have to decide before because they stab you so quickly after the birth with the injection you're not capable of making a decision!

I had the injection but still bled like crazy so I don't fit the figures for lower PPH with managed 3rd stage.

Completely agree its prudent to decide before you're too far into labour to remember you care. But that's very different to saying you have to give a definite yes/no at about 37 weeks - I can't see any justification for that.

I wanted (and had) a physiological third stage with DD. I told the MW when I arrived in hospital 7 cm dilated and we agreed that I would have the injection if medically necessary. I don't think you need to decide at 37 weeks either (just research it I guess) but I think they tend to give the injection as standard at some point towards the end of the second stage so you don't notice it, so would need to tell them before then.

I can't actually remember my reasons but know I looked into it so assume they were good reasons and will try for the same again this time. MW was fairly anti it btw - she told me it would take an hour. Actually took 12 minutes and a single push - sooooo nice after 90 min of pushing out DD! - think she was probably latched on and nursing by then, which might have helped.