Pros and cons of physiological 3rd stage please!

[LaTristesse]

Am considering whether to go for a physiological 3rd stage this time - had the injection with DS while they were stitching my episiotomy up - although I'd hoped for a natural one then too.

What are the advantages and disadvantages please? And does it matter that it's DC2 - will it be more painful, slower etc?

Thank you!

Advantages:
You have longer to get the placenta out - a placenta trapped behind a closed cervix (which can happen once syntometrine is given) can contribute to PPH and therefore the risk of retained placenta and needing manual removal is reduced.
Can take longer to get third stage over with
Some midwives aren't comfortable with physiological third stage or aren't aware that they shouldn't touch the cord or apply gentle traction to it without drugs
Fewer drugs in your system

Disadvantages
Increased risk of PPH if your uterus doesn't contract efficiently once baby is born (although syntometrine can be given at any time, it doesn't have to be within seconds of the birth)
Shorter time to deliver placenta once injection is given so you're on a shorter clock although it is usually effective at delivering the placenta fairly quickly (however if it hasn't been delivered within so many minutes afterwards then you may need manual removal)

Prophylactic use of syntocinon (one of the drugs used) has been shown to be less effective when used in subsequent pregnancies (eg if you have it 'just in case' in one pregnancy, then it is less effective next time it is used) - I think that research was done by Professor Cecily Begley at Trinity College, Dublin. Her research also showed that there was no increased risk to mothers from watching and waiting and administering syntometrine if it was necessary as it still only takes a few seconds to get into the system.

I've looked into this a lot as I had a PPH and retained placenta first time round, and am planning a homebirth with physiological third stage this time round. The Supervisor of Midwives didn't disagree with anything I said to her about the above :)

I tried to have a physiological 3rd stage with DC2. I say tried because I did end up having the injection 50 minutes after my DS was born. In those 50 minutes, I didn't really get the chance to bond immediately with my DS as both myself and the MW were preoccupied with delivering the placenta which just wasn't coming out by itself. The MW was suggesting different positions I could go in to help it on it's way and encouraging me to give little pushes (not sure if all of this was the right thing to do, I just kind of went along with what the MW was saying!).

After 50 minutes, I just really wanted to relax, clean myself up and most of all just sit and gaze at my DS so I asked for the injection. The placenta came out within a couple of minutes and I have to say, I found this quite painful. It was like pushing another baby out!

Afterwards, the MW told me she was glad I had decided to opt for the injection in the end as I was getting close to the point where I would have had to have the placenta surgically removed, which would have been even more time away from my DS.

I don't regret it for a second and with DC3 (who was a homebirth) I decided to have the injection and not try again for a physiological 3rd stage. I can definitely see why people go for it, and had it all gone to plan I am sure I would have been very happy that it happened for me, but in the end it only had a negative impact on my birth rather than a positive one.

Thanks ladies! (Fliss, do you have an 'Idiot's Guide...' version of what you said!? - no seriously, I think I understand...)

Flossy can I ask with your DC3 and the injection, was it as painful as with your DC2?

Breastfeeding immediately (if you can) and being left to bond with your baby are actually meant to help deliver the placenta Flossy - the oxytocin release helps the uterus to contract and encourages the placenta to shear off, so it's not surprising that yours didn't come away naturally.

If you're having a physiological third stage, the idea is to 'watch and wait' - sounds like your MW wasn't entirely comfortable with that and felt that she 'should' be doing something to help things along (ie changing position and pushing), when actually the best thing she could have done is just observed and then suggested the injection later if doing nothing didn't work.

If nothing didn't work? Appalling grammar, sorry ladies. If nothing worked.

I had an experience very similar to Flossy with DD. DD and I had 20 mins or so of snuggles and then it was all "squat over this dish and push when you feel a contraction" - I got annoyed after about 45 mins and asked for the injection. The placenta came out with cord traction within 5 minutes and all was fine.
Am currently pg with DC2 and will probably ask for the injection if the placenta doesn't plop straight out (but I will refuse it until the cord has stopped pulsating).

I had a managed third stage with DC1 ( by choice ) and had opted for a managed 3rd stage with DC2 due to low platelets but she took us all a bit by surprise and the MW hadn't got the injection ready so I had a physiological third stage. DD helped by latching on immediately after birth and I think the placenta arrived about 30mins later. I vaguely recall having to push and having contractions but had DD on me the whole time. It was all fine.

Watching this thread with interest!

I would really like to go for a physiological third stage, but have concerns (probably unfounded!) about some of the issues mentioned above.

I've heard allowing blood to flow back to the baby from the placenta is really beneficial which is my main reason for wanting a physiological 3rd stage. As such I would like to at least wait until this has happened before either the cord is cut or I'm offered an injection. How long does it normally take before the placenta is no longer of 'use' so to speak?!

LaTristesse - I forgot to add that I didn't need the injection for DC3 in the end as I had the rare occurrence of delivering the placenta with the baby, so my DS was born and no more than 3 seconds later the placenta came out of it own accord. I was all ready to have it and they only realised the placenta was out when they went to give me the injection! Sorry, completely missed that point off my other post so sorry can't answer your question.

Fliss - I wished at the time I could just forget about delivering the placenta and just cuddle my newborn but the MW's preoccupation with it meant I couldn't relax. Also, as my DS was born at 37 weeks he was really sleepy and took some encouragement to breast feed! He wasn't interested until about 2 or 3 hours after he was born.

In different circumstances (i.e. my son being born a few weeks later, the MW being more supportive, me being more decisive about the way I wanted things to happen etc) I may have had a completely different 3rd stage and could be telling you how wonderful it was. Unfortunately, that wasn't the case and as thing has had a similar experience I think it's worth taking on board that you could end up in this kind of situation. I am not saying don't do it as everyone has different ideas, needs and experiences of birth and should do what they feel it best for them. I just wanted to give you my personal experience so you are armed with more facts when making the decision.

I did a physiological 3rd stage with DS... Was just lying there about 20 mins after the birth and suddenly body did an unexpected contraction. DH was terrified and midwife was out in the corridor!

Not sure what made it come out so easily - maybe skin to skin snuggling with DS - hadn't tried BFing by that point.

FWIW we also took our placenta home and buried it next to a tree we planted for DS and will do the same with our next ones... They were keen to make sure we weren't planning to eat it though.

I had a physiological third stage this time

Was lovely. I fed DD, had a cuddle and chat with DP, then after a while the mw said try a little push, I did a few pushes and out it came

I realise I was v lucky, and I'd had a quick straightforward birth which no doubt contributed. Also I hadn't been up in labour all night and so I wasn't stupidly knackered like lots are. I totally understand that if you've been in labour for days and pushing for hours you might just like it all over as soon as possible

The AIMS book 'Birthing your Placenta' is really helpful when it comes to making the decision or at least arming yourself with some information, it costs £8.00 and is available from their website

TheBreadstick I think you can be guided by the time it takes for the cord to stop pulsing (which means the blood flow has stopped). I think that can take up to 15 minutes, but I don't know why I have that time in mind.

Some women don't have it cut at all and leave the placenta and cord attached to baby until it drops away naturally - I think that's a lotus birth but am not completely sure!

I've had 2 physiological third stages after homebirths with DCs2 and 3. Both were waterbirths. each time it took over an hour for the placenta to come out. Both times the midwives literally hovered over me making comments, wondering if I should sit on the loo or sttand up, suggesting that might be quicker. The first time the MW tried cord traction, despite that specifically being inappropriate and stated on my birth plan I did not want it done. I told her to desist and she did. Eventually I stood up like she wanted me to, and nothing happened. DD hadn't latched on by then (despite uninterruped S2S) and it suddenly dwaned on me that nipple stimulation might help. I twiddled a nipple, one contraction and out it plopped right onto my feet, yuk.

The second time after the MW started making noises about gettting up and moving to the loo I told her in no uncertain terms it would take ages (just like last time) and that I was busy feeding and having uninterruptes S2S with my baby and would continue to do so for as long as I wanted. Placenta could come when it was good and ready and she'd have to wait. After that she shut up, but still hovered beneath my legs, which I didn't like. Contractions resumed before it came out and it took several.

Both times the contractions for the placenta were more painful than my relatively pain free hypnobirths.

I am sure all the hovering actually slowed it down. It was v distracting.

That's really interesting Pesto thanks. We'll be Hypnobirthng again too and I was wondering whether you're meant to breathe down the placenta the same way you do with the baby. I can't see mw's understanding this if they can't get their heads round 'don't pull on the cord'! Good to hear you can be forceful and get them to back off though!
I think I'm going to give it a go, as I do feel a bit aggrieved that the option was taken away from me last time...
And it seems like I can always opt for the injection at a later stage if nothing happens...
Thanks for all the feedback ladies!

I had almost exactly the same experience as Flossyfloo. It took 54 mins for the placenta to come out (I asked for my notes on it) and was encouraged to hand the baby to my partner and try to push it out. I felt like I was pushing on nothing, and had no energy anyway. Midwives were getting stressed, so I was getting stressed about having to go to hospital for placenta removal etc.

Midwife I spoke to last week said they want it out in an hour. The midwife I saw today said no, 2 hours would be fine. Independent midwife I asked said 2-3 hours perfectly normal. I'm guessing there's a certain amount of NHS protocol around wanting it done so as to move on to giving attention to another lady in labour - and I understand that. But the midwife I saw today said I should have been encouraged to keep breastfeeding etc which would help get it out.

I had planned to ask for a managed 3rd stage this time, but having chatted to the mw today I think I'll stick with physiological - but this time will be prepared to stand my ground that I will be holding/feeding my baby, and won't be pushed into thinking that approaching an hour is too long.

I've had 3 natural third stages. Or perhaps two and a half as with the first one the MW was not used to the concept and I'm not convinced the cord had stopped pulsating before she clamped and she was pulling on the cord for ages. With my IM for the others, she asked me to push after 21 minutes (her practice 'joke' - they had observed around 20 mins was a very common time so started asking women to try pushing around then and it worked). The cord was cut just before, although with the waterbirth I wish we'd left it until afterwards as I had to fish around in the pool trying to find the placenta - if it was still attached to the baby it would have been easier.

Like others have said above I attempted it but after 45 mins got fed up with having this thing attached to me (as in the placenta nit the baby!) and just wanted it out! I had a hb and I felt no pressure by mws who just sat back and chatted to me as I fed and took loads of photos of baby (never to be shown to anyone due to the state I am in!).

We are ttc for a 2nd and I have to say next time round I want the cord to stop pulsating but then will get the injection.

i have had pschological third stage with some of mine, i found it fine, couldnt do it with ds1 and dd (no 5) as i had had the syntocin drip, i think they also dont recomend if if you have had pethidine? but not sure about that.

anyway it was fine, i just snuggled my baby and bfed and had no problems delivering the placenta, was fairly quick as well, BUT i found that the contractions i had to deliver the placenta were still qiute painful, wheras on the occasions i had the injection they werent. that could have jsut been me tho?

ds4 was the best, had him in the pool, very quick birth and stayed in the pool holding ds4 to deliver the placenta (not all midwives like you doing this, mine was fine, infact she suggested it) it really didnt take very long at all and i found being in the water meant i was relaxed etc and i didnt really feel it coming out, tho did feel the contractions.

btw a lotus birth is where even once the placenta has been delivered you dont cut the the cord, you leave placenta and cord attached to the baby until it comes away naturally, normally in a few days, the placenta is normally kept in a bowl and some people salt it? google its interesting but not for most people, i considered it as i thought it would make people less likely to want to take baby off me and hog them for cuddles!

"Lotus birth, or umbilical nonseverance, is the practice of leaving the umbilical cord attached to both the baby and the placenta following birth, without clamping or severing, and allowing the cord the time to detach from the baby naturally. In this way the baby, cord and placenta are treated as a single unit until detachment occurs, generally two to three days after birth."

here from wikepedia :)

As I thought then, no cutting involved!

no no cutting when i had ds4 in the pool they didnt cut the cord till after the placenta has arrived, they did clamp it once it stopped pulsating tho. i assume they didnt cut it as it was easier to fish it out the water?! as soon as it was out they then cut the cord.

i am intrigued by the idea of not cutting and leaving the placenta to detach naturally but not enough to try it!

...quicker than I expected so cord was cut before it had fully stopped pulsing at my request and I then delivered the placenta within 30-40mins.

Oh god, don't know what went wrong then. Basically pro natural 3rd stage especially due to vomiting from the injection (about 30% of women with syntometrine).

article about lotus birth