third stage: retained placenta, allow to pulsate next time or cut?

[Joygirl78]

Hi. I had a horrible third stage with DC1. They cut cord immediately (pretty much standard practice) and suggesed natural third stage. It didn't expel, and I started to experience severe excruitating pain. They tugged and decided to turn epi on (had been off for second stage) then they gave me that jab. By this time I was literally screaming and vomiting violently. It was horrific. Eventually the placenta did come, moments before they were going to take me to theatre to get it out. I ended up in shock.

I have read that there are big benefits to not cutting cord immediately for baby. Why is it then that they usually cut it so quickly? What are the benefits to that, and the risks or negatives to allowing it to pulse? If I do request that it is allowed to pulse and cut later, do I stand the same risk of retained placenta?
Anyone knows? Thanks :)

It doesn't sound like you had a retained placenta - it sounds like it was mis-managed 3rd stage.
The argument (if u like) for not having the injection is that it allows the baby to take any extra blood/oxygen from the cord, that it may require. You should then be encouraged to BF asap (if the cord is long enough) and then wait for nature to take it's course. Expelling the placenta this way can take in excess of 1 hr, which is fine (as long as you'e not bleeding). The cord should never be tugged in this case. You push the placenta out in the same way as you pushed the baby out. Then the cord can be cut.

This approach does not sit well in modern obstetrics.... mainly because it is slow. Many midwives need to be finished with the suturing, paperwork etc within about an hour and can't sit about waiting for a placenta. Sad, but true.

If there has been any intervention or deviation from the normal then the injection will be offered/recommended. This includes longish labours, epidurals, instrumental deliveries, more than 4 babies etc. Most of this is not strictly enidence based but is the way it is.

If they are going to 'actively' manage your 3rd stage then the cord needs to be cut immediately at delivery. The MW will then wait to feel your uterus has contracted and pull the placenta down through the birth canal. This should not be painful.

Complications, like what you experienced, happen when the two styles of management are mixed. I.e.you leave the cord for a bit and then decide to tug on it, then give the injection, then clamp it....

I suggest you have a discussion with a MW who knows what she is talking about with regards to the pros and cons of not having the injection. I am sorry you had such a horrible experience.

Thanks for your response. I am confused about what you say about complications. My cord was cut immediately, and then left to expel naturally rather than as you say above, I did experience the most awful pain, and was only then given the injection.
If I don't have it cut, and let it pulsate for a bit - even just for a few minutes to allow blood to flow - can I then opt for the injection to ease it's extraction? Can't ask midwife as my next appointment isn't for 2 weeks and I am likely to deliver before then?

The pros of a managed third stage are quicker third stage, less chance of PPH. It helps the uterus clamp down to expel the placenta which can mean less chance of a retained placenta (the uterus cannot clamp down and seal off the blood vessels properly with the placenta still in there) Baby can be cleaned and weighed more quickly as the cord is cut and baby is therefore more mobile!

Downsides - less time for placenta to come out before the cervix closes, baby doesn't get the full amount of cord blood and this can mean lower iron levels, one study has shown that prophylactic use of syntoncinon (one of the ingredients in syntometrine) can reduce it's efficiency next time it is used - ie if you have it in your first birth, then it is slightly less efficient (so it's not necessarily a good plan to give it to all women 'just in case' but that needs further research)

The pros of a physiological third stage - fewer drugs into your system, baby can be left attached to you for as long as necessary, breastfeeding immediately should help with the detachment of the placenta, you can keep baby next to you without anyone suggesting they take baby now to weigh/clean/measure etc. The placenta may take longer to deliver but you reduce the risk of the cervix clamping down with the placenta in place leading to retained placenta. Retained placenta is a cause of PPH.

Downsides - Chance of PPH due to the uterus not expelling the placenta quickly. Baby is attached to you until either the placenta is delivered, or the cord is cut, so you can't pass him/her to anyone else or move without baby being there.

Prof. Cecily Begley at Trinity College in Dublin has done research into managed vs physiological third stages, and has found that there is no increased risk from waiting and seeing if the injection is needed to reduce bleeding instead of giving it at the moment of birth. Even if it's given later on if the placenta hasn't delivered, it will still only take seconds to do it's thing.

Most MWs will want the placenta delivered within an hour of the baby being born, however the AIMS book 'Birthing your Placenta' states that this one hour limit is seemingly arbitrary and not actually based on any evidence - Mary Cronk has said that she's been with women who have taken up to 3hours + (IIRC) to deliver a placenta naturally but have done so safely.

I had a retained placenta which was manually removed AND a PPH first time round, and am opting for a physiological third stage this time unless I have another PPH. I did have lots of intervention in my first birth though which could have contributed to these things happening, and so I have planned a homebirth this time round to try to minimise intervention and therefore reduce the risk of PPH and retained placenta further.

So in short, yes, you can wait for the placenta and then have the syntometrine jab after a while if you want it.

Sorry - to clarify. There are 2 styles of management of 3rd stage. Active & physiological.

Active is cut cord immediately, injection is given (normally with delivery of baby's shoulders), uterus is felt to be contracted by MW and gentle traction applied to cord and placenta delivers.

Physiological - leave cord to pulsate, wait for contraction to happen naturally, mother expels placenta through effort.

It is not very good practice to 'mix' these styles of management. You say your cord was cut straight away (active) but you were left to expel it naturally (physiological). This, from my experience, is how the problems arise. You either opt for one or the other. This is not to say that should you opt for physiological and then decide to change to active, or you start bleeding etc that you can't change your mind...you can...but it should be one way or the other. From what you say, it sounds like an odd choice of clinical management. It does not suprise me that you encountered problems/pain.

If you are not going to get chance to see your MW before del then perhaps it would be wise to talk this through with someone else who can agree a plan for your notes. You don't really want to be turning up in labour and having to chat things through.

I wish you well.

Excellent, informed post btw Flissapps

Thanks maccapacca. This really helps, and I think does explain why things went wrong. God only knows why they cut and then left it. I was delirious after 36 hour labour and no sleep, it is all a haze which ended horribly with a lot of vomit!!! Will make sure we avoid this mess as soon as this baby decides to hurry up and come out....

Maccapacca Thank you. Having had a retained placenta and PPH first time round (following a very intervention heavy birth) it's something that I've done a lot of reading up on as I have no medical knowledge at all and am hoping to avoid the same happening this time round if at all possible!